Exercise-induced Hypertension: Benign or Predictive?

As a general internist (formerly a nephrologist), I always try to treat hypertension to target or below. I also address other risk factors, such as elevated lipids, as often as possible. But I recently discovered that I do not pay close enough attention to blood pressure readings taken before or after stress testing (or other monitored exercise). Let’s look at another important risk factor for hypertension that may not get enough attention.

1. Which of the following statements regarding the predictive value of hypertension occurring during exercise on a bicycle (6 minutes) or Bruce protocol stress testing is/are true? (More than one may be correct)

A. Adjusted for other cardiac risk factors, a systolic pressure between 200-275 mm Hg is associated with a 1.39 greater risk of cardiovascular (CV) mortality over a 35-year follow-up than a systolic pressure of 100-160 mm Hg.

B. Systolic but not diastolic hypertension with stress testing predicts future hypertension.

C. A delayed decline of systolic blood pressure during recovery from exercise predicts severe coronary artery disease. 

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The correct answer is: A and C are true; B is false

In a 35-year follow-up study, approximately 2000 men did a 6-minute bicycle exercise test. Blood pressure was measured before exercising and every 2 minutes during the test. The 1.39 greater risk of cardiovascular mortality was demonstrated in the cohort in which systolic blood pressures during exercise peaked at 200-275 mm Hg.¹

Although systolic hypertension during Bruce stage 2 exercise/stress predicted the development of future hypertension in subjects without a history of hypertension, diastolic hypertension did as well.²

In 1999 it was reported that a delay in the decline of systolic pressure was more accurate than ST segment depression in diagnosing coronary artery disease.³

2. Which one of the following statements regarding exaggerated blood pressure levels during exercise
in adolescents is true?               

A. In adolescents (n=3,949) who had exercised and experienced a post-exercise systolic blood pressure ≥ 150 mm Hg, left ventricular mass was 7% greater than in adolescents who had a post-exercise systolic pressure of < 150 mm Hg.

B. Adjusting for body composition (fat mass) negates the blood pressure-associated increase in left ventricular mass.

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The correct answer is: A is true and B is false

In this study, adjustments for lean body mass attenuated, but did not abolish the association of exercise blood pressure and left ventricular mass. The left ventricular abnormality was not solely associated with increased weight.⁴

3. Choose the single most accurate statement below:

A. Exaggerated systolic hypertension in persons without a diagnosis of hypertension during the early stages of the Bruce protocol exercise test does not correlate with a diagnosis of hypertension.

B. A patient without a diagnosis of hypertension who develops systolic hypertension (> 150 mm Hg) only during stress testing should be suspected as having hypertension.

C. Early exercise-stress-testing hypertension is a transient phenomenon and does not persist after exercise.

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The correct answer is B.

The study utilized ambulatory blood pressure monitoring to document the presence of hypertension without exercise. The authors concluded: “Exaggerated exercise blood pressure should be a warning signal to health/exercise professionals on the presence of hypertension and the need to provide follow-up care to reduce cardiovascular risk.”⁵

References

Mariampillai JE, Engeseth K, Kjeldsen SE, et al. Exercise systolic blood pressure at moderate workload predicts cardiovascular disease and mortality through 35 years of follow-up in healthy middle-aged men.  Blood Pressure. 2017;26:229-236.

Weiss SA, Blumenthal RS, Sharrett AR, et al. Exercise blood pressure and future cardiovascular death in asymptomatic individuals.Circulation. 2010;121:2109-2116.

McHam SA, Marwick TH, Pashkow FJ, Lauer MS. Delayed systolic blood pressure after graded exercise. J Am. Coll. Cardiol. 1999; 34:754-759.

Schultz M, Park C, Sharman J, et al. Exaggerated exercise blood pressure is associated with higher left ventricular mass in adolescence: the Avon longitudinal study of parents and children.J Hypertens. 2016; 34 (Suppl 1) e55.

Schultz MG, Picone DS, Nikolic SB, et al. Exaggerated blood pressure response to early stages of exercise stress testing and presence of hypertension. J Sci Med Sport.  2016; 19:1039-1042.