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Transcript of Clinical Significance of an Exaggerated Blood Pressure Response During Exercise ANDREAS PITTARAS MD.
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Clinical Significance of an Exaggerated Blood Pressure Response During Exercise
ANDREAS PITTARAS MD
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Patient A Patient B
Age 67 58
Rest BP 120/80 120/78
BP @ 5 METs 160/80 220/90
Peak BP 190/80 230/100
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QUESTIONS
• The Clinical Significance?
• What to do about it?
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Definition
• Peak Exercise SBP >210 mm Hg for men and 190 mm Hg for women respectively (Framingham)
• SBP >200 mm Hg at Exercise Workload of about 6-7 METs
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Exaggerated BP Response toExercise and Associations
• Future Development of HTN
• Cardiovascular Mortality and Cardiovascular events
• Left Ventricular Hypertrophy
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Clinical Significance
False-positive results were twice
as likely in patients with hypertensive response to
exercise echocardiography
(22% vs 12%).
Jong-Won Ha, et al. JACC 2002:112:161-66
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Exaggerated BP and Future Development of
Hypertension
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New-onset of HTN and Exercise BP in Men (n=1026) The Framingham Heart Study
1.36
2.17
1
4.16
0
2
4
Women Men
Odds Ratio
DBP
SBP
*
*
Singh JP, et al. Circulation 1999;99:1831-36
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Exaggerated BP Response to Exercise and Risk for Developing HTN (n=1,033)
1 1
3.7
2.89
6.62
4.91
0
2
4
6
8
Multiple Adjusted Age-Adjusted
Miyai, et al. Hypertension 2002;39:761-6
DBP
SBP
4.7 yrs F/U
Relative Risk
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Exaggerated BP Response to Exercise and Risk for Developing HTN
3.82
3.17
1.08 1.05
0
1
2
3
4
Exag-BP Resting HTN BMI Age
Miyai, et al. Hypertension 2002;39:761-6Relative Risk
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Exaggerated Exercise BP and Future HTN (Conclusion)
• Overall, an exaggerated BP response to exercise is likely to lead to future HTN
• Confounding factors such as age, gender, and physical fitness have not always been considered
• Pre-hypertension ?
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Patients with Pre-hypertension are at twice the risk to develop
hypertension compared to those with lower BP values.
Vasan RS, et al. The Framingham Study. JAMA 2002;287:1003-1010
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Exaggerated BP and CV Events and CV Mortality
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Exercise BP and CV Mortality in Middle-aged Men (n=1999)
5.6 6
8.1
16.1
0
9
18
%
<140 / <200 mm Hg
>140 / >200 mm Hg
<140 / >200 mm Hg
>140 / <200 mm Hg
Mundal et al. Hypertension 1994;24:56-62
* RR=2.0
NS
F/U: 16 yrs
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Exercise BP and Risk of Developing MI in Middle-aged Men (n=1999)
9.5
18.8
11.4
15.7
5
10
15
20
%
*
<140 / <200 mm Hg
>140 / <200 mm Hg
>140 / >200 mm Hg
<140 / >200 mm Hg
Mundal et al. 1996; Hypertension;27:324-29
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Conclusion
SBP >200 mm Hg at exercise intensity of about 6 METs is a stronger predictor of CV and MI morbidity and mortality than resting BP In pts with resting HTN.
Mundal R. et al., Hypertension 1996;27(1):324-29
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Exaggerated BP Response and
Left Ventricular
Hypertrophy
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Resting BP is weakly related to LVH (r=0.26) and can only partially
explain its development
and progression.
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Exaggerated BP & LVH in Normotensive Men
An exaggerated blood pressure (SBP >210) at peak exercise is associated with left ventricular hypertrophy (LVH). The association is much
stronger than that between resting BP and LVH.
Gottdiener JS., et al. Annals of Internal Medicine 1990; 112:116-66
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Peak Exercise SBP and LV MASS
224 222
180
155
143
124
110
140
170
200
230
Peak SBP LVMI
HTN with SBP >210 mm Hg
<210 mm Hg
Polonia J, et al. Eur Heart Journal 1992; 13(A):30-36g/m2
>210 mm Hg
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Peak Exercise BP and LV MASS
220
176
124
103
80
110
140
170
200
230
Peak SBP LVMI
<210 mm Hg
Molina L, et al. Am J Cardiol 1999; 84:890-93
>210 mm Hg
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Peak Exercise BP (SBP>210 mm Hg) and LVH in Men & Women
106
111
74
80
60
80
100
120
Men Women
<210 mm Hg
>210 mm Hg
Lauer et al. Annals Intern Med 1992;116;203-10g/m2
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Conclusion
The relationship between Peak exercise BP and LVM is
confounded by a number of baseline variables so that its
biological significance must be questioned.
Lauer et al. Annals Intern Med 1992;116;203-10
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Peak vs Sub-maximal Exercise BP
Peak Exercise BP
–Relatively difficult to assess
–Impractical
–Based on a relative workload
Exer. BP (5-7 METs)
–Easier to assess
–Practical (reflects daily activities)
–Wider clinical application
–Based on absolute workloads
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Exercise SBP and Fitness in Normotensive Men (n=1,025)
161
149
140
173
166
153
178
182179
125
145
165
185
SBP @ 5 METs SBP@ 7-METs Peak Exercise
*
* p<0.01
mm Hg Low-Fit Moderate High-Fit
*
*
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Patients with Pre-hypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg), are at twice the risk to develop hypertension compared to those with lower BP values.
Vasan RS, et al. The Framingham Study. JAMA 2002;287:1003-1010
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LVMI Predictors for Pre-HTNsiveMen (Multiple Regression)
M (n=269) W (n=243)
R2 R2
• SBP @ 7 METs 0.62 0.50
• Age 0.64 0.51
• T-Time 0.65 0.53
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LVMI & Exercise SBP Association in Pre-Hypertensive Women
Kokkinos P, Pittaras A et al. Circulation 2004
SBP at 7 METs
240220200180160140120
LV
MI
(kg
/m2
)
200
180
160
140
120
100
80
60SBP>169 mm Hg
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LVMI & Exercise SBP Association in Pre-Hypertensive Men Kokkinos P., Pittaras A et al. Circulation 2004
SBP at 7 METs
220200180160140120
LV
MI
(kg
/m2
)
200
180
160
140
120
100
80
60SBP>164 mm Hg
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LVMI & Exercise SBP in Pre-hypertensive Men and Women
133
96
120
92
75
85
95
105
115
125
135
Women Men
*
* p<0.01
Normal
EX-HTN
*
Kokkinos P., Pittaras A et al. Circulation 2004g/m2
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Prevalence of LVH in Pre-HTNMen % OR CI p-value
–EX-HTN (+): 59 30.2 13.8-66.2 0.00–EX-HTN (-) : 4.5
–RR= 5.9 times higher likelihood of LVH/10 mm
Hg Increase in SBP@ 6 min. of exercise
Women–EX-HTN (+): 86 21.6 12.3-38.2 0.00–EX-HTN (-) : 22 –RR= 2.9 times higher likelihood of LVH/10 mm
Hg increase in SBP@ 6 min. of exercise
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Conclusions• Systolic BP at about 6-7 METs is the strongest predictor of LV mass in Pre-hypertensive men and women.
• The threshold for LVH is SBP >164 mm Hg for men and >169mm Hg for Women.
• The likelihood of having LVH increases by 6-fold in men and 3-fold in women for every 10 mm Hg increase in SBP above these thresholds.
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What to Do for Patients with Exaggerated BP Response
to Exercise ?
• Antihypertensive Agents
• Exercise Training
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Exercise BP and Antihypertensive Meds (n=1,977)
151
167164
182 175
192
145
170
195
SBP@ 5 MET SBP@ 7 METS SBP @ Peak
*
** p<0.01BB-Based
Others
*
*
mm Hg
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Exercise BP and Antihypertensive Agents (n=1,977)
152
166164
166164
180182
181
140
155
170
185
SBP@ 5 MET SBP@ 7 METS
* p<0.01
BB-Based
ACE
CCB
Diuretics
mm Hg
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Clinical Significance
Beta-blockade may be a prudent approach to protect against excessive and repetitive elevations in BP likely to occur during vigorous activities such snow-shoveling basketball, tennis, etc., that require repetitive burst of effort to maximal or near maximal levels.
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What to Do for Patients with Exaggerated BP Response
to Exercise ?
• Antihypertensive Meds
• Exercise Training
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Exercise Indices for Fit and Unfit Women
Normotensive Fit (n= 557) Unfit (n=463)
SBP- 6 min 145±18 156±20*
HR- 6 min 136±15 152±17*
Hypertensive Fit (n= 99) Unfit (n=186)
SBP- 6 min 172±21 184±21*
HR- 6 min 141±15 156±15*
Kokkinos P. Pittaras A et al, J Cardiopulmonary Rehab 2002;22:178-183
* p =0.000
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Exercise BP, Fitness & LVMI in Men
184
175
165
135
125
117
106
126
146
166
186
SBP @ 7 METs LVMI
*
*
* p<0.01
Pittaras A, et al. Circulation 2003
Low-Fit
Moderate
High-Fit
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Exercise BP, Fitness & LVMI in Women
187
177
167
140
127
117
100
130
160
190
EX-BP LVMI
*
*
* p<0.01
Pittaras A, et al. Circulation 2003
Low-Fit
Moderate
High-Fit
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SBP Following Aerobic Training
138131
198
171
219
187
219
199
120
140
160
180
200
220
Rest 6-Min 9-Min Peak
*
*
*
*p<0.01
*
Kokkinos P. et al, Am J Cardiol. 1997
mm Hg
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Wall Thickness at Baseline and 16 wks
12
13
14
15
PW IVS
mm
Kokkinos, Pittaras A et al. New Engl J Med 1995;333:1462-7
*
*
* p<0.05
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LVMI at Baseline and 16 Wks of Exercise
163
143
135
150
165
Kokkinos, Pittaras A et al. New Engl J Med 1995;333:1462-7
*
* p<0.05
Baseline 16 weeks
g/m2
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Antihypertensive Agents and Exercise
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Exercise SBP and Fitness in Hypertensive Men on B-Blockers (n=453)
156
146
136
171
163
155
173 174
170
120
140
160
180
SBP @ 5 METs SBP@ 7-METs Peak Exercise
*
* p<0.01
mm Hg Low-Fit Moderate High-Fit
*
*
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Exercise SBP and Fitness in Hypertensive Men on Meds (n=455)
179
163
155
193
181
170
196193 192
140
160
180
200
SBP @ 5 METs SBP@ 7-METs Peak Exercise
*
* p<0.01
mm Hg Low-Fit Moderate High-Fit
*
*
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Does exercise BP at 5-7 METs reflect daytime Ambulatory BP?
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Exercise BP & ABP in Fit & Unfit Men
151
159
126
144147
111
100
115
130
145
160
Unfit Fit
EX-BP
ABPM
LVMI
LVMI
EX-BP
ABPM
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Exercise BP & ABP in Fit & Unfit Women
153
164
133
143148
113
90
105
120
135
150
165
Unfit Fit
EX-BP
ABPM
LVMI
LVMI
EX-BPABPM
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Summary and Conlusions• Fit individuals have Lower:
• BP at intensities of 5-7 METs• Lower ABPM • Lower LVMI Than Unfit.
• Physical activity lowers the daily hymodymanic load, leading to lower LV Mass.
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Mitigates the hemodynamic load
During Daily Activities
Prevents or Attenuates Increases
in LV Mass
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How Much Physical Activity?• Some is Better than None!
• Choose an activity you enjoy
• Start Low & Progress Slowly
• Start as low as 10 min/week
• Split duration (AM/PM) if needed
• Increase duration by 1-2 min/wk
• Goal: 100-200 minutes/week
• Be Consistent (2-6 times/week)
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How Much Physical Activity ?
Think F.I.T
F- Frequency: 2-6 days/Wk
I – Intensity : 60-80% of HRR
T- Time : 100-200 min/week
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• The daily hemodynamic load is likely the impetus for the
development and progression of LVH. • SBP at 5-7 METs of exercise reflects the hemodynamic load during daily activities.
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Therefore, attenuating
an abnormal rise in BP during daily physical
exertion may prevent the development and/or
maintenance of LVH.
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Conclusion 1
High fit Women had:
• Lower LVMI • BP @ 6 min of Exercise
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• The metabolic demand of about 6-7 METs at 6 min of exercise (Bruce protocol) is equivalent to that of most daily activities. Thus, the 6-minute exercise BP may reflect the hemodynamic load during daily activities.
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• Furthermore, the maintenance and progression of LVH may be mediated by this daily hemodynamic load. Thus, attenuating an abnormal rise in BP during daily physical exertion may prevent the development and/or maintenance of LVH.
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Correlation of 6-minute Exercise SBP, LVMI and Daytime ABP in Men
SBP@6-min ABPM
LVMI
r=0.73
r=0.81 r=0.68
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Correlation of 6-minute Exercise SBP, LVMI and Daytime ABP in Women
SBP@6-min ABPM
LVMI
r=0.79
r=0.71 r=0.67
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Peak Exercise DBP Before and After Exercise Training in Women
97
9394
89
80
90
100
Baseline 4 wks 8 wks 12 wks
Seals et al, Am J Cardiol ‘97mm Hg
P<0.05
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Peak Exercise SBP Before and After Exercise Training in Women
183
176
171
162
150
170
190
Baseline 4 wks 8 wks 12 wks
Seals et al, Am J Cardiol ‘97mm Hg
P<0.05
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Exercise RPP at Pre & Post Training
15
20
25
30
35
6 min 9 min Peak
RP
P *
100
0
*
*
*
*p<0.05
Kokkinos P. et al, Am J Cardiol. 1997
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Exaggerated BP & False-Positive Exercise Test Results
Jong-Won Ha, et al. JACC 2002:112:161-66
• 132 pts with Peak Exercise SBP>220 mm Hg for Men; > 190 mm Hg for Women
• 108 had positive exercise Echo finding
• 24/108 (22%) had no significant CAD
• 416 pts with Normal Exercise BP
• 320 had Positive Exercise Echo Findings
• 39/320 (12%) had no significant CAD
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Exercise Response for Pts on Beta-Blockers vs Other Antihypertensive Meds
Variables Others (n=1254) BB (n=561) Δ
SBP @ 3 min 167±27 151±26 16SBP @ 6 min 182±27 164±25 18 Peak SBP 192±28 175±30 17HR @ 3 min 119±17 106±17 13HR @ 6 Min 133±16 119±18 14Peak HR 148±17 31±21 17Ex. Time (sec) 412±166 419±160 7
P<0.001
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BP Response to HR During Exercise Test and Risk of Future Hypertension
Miyai N, et al. Hypertension 2002;39761-66
• N=1033 Men, No HTN, DM or CVD• Cycle Ergometer; Automated BP
monitoring device.• Age: 42.9 ±8.5 yrs; range: 20-59 yrs• 726 pts with complete data; • 4.7 yrs F/U
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Exercise BP Predicts CV Mortality in Middle-aged Men
Mundal et al. 1994; Hypertension;24:56-62
• N=1999 healthy men
• F/U: 16 yrs
• Exercise BP at 600 kg-m/min (~100 watts; approximately 6 METs)
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Peak Exercise SBP and LV MASS
152
174
190
124
143
155
100
120
140
160
180
200
BP @ 3 min LVMI
HTN with SBP >210 mm Hg
<210 mm Hg
Polonia J, et al. Eur Heart Journal 1992; 13(A):30-36g/m2
>210 mm Hg
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• SBP at sub-maximal exercise reflects the daily hemodynamic load.
• Therefore, it may be a stronger predictor of HTN and LVH.
• Sub-maximal exercise BP may also have a wider clinical application than maximal exercise BP.
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• Left ventricular hypertrophy (LVH) is a powerful and independent predictor of cardiovascular events in patients with and without obstructive coronary disease.
• The risk for CV morbid events, including sudden cardiac death, increases-three fold in patients with LVH.
Levy D., et al. N Engl J Med 1990;332:1561-66
Ghali JK et al., 1992; Ann Intern Med 1992;117:831-36
Koren MJ et al., 1991; Ann Intern Med 1991;114:345-52
Casale PN, et al., Ann Intern Med 1986;105:173-78
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Clinical Characteristics
Men Women
N 269 243 Age 49±10 54±10 RHR 78 ± 8 82 ±14RSBP 129 ±6 132 ±7RDBP 76±7 79 ±8 BMI 27±2.6 27±2.4
* p =0.008
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Exercise SBP and Fitness in Hypertensive Men (n=908)
151
171
164
185173
195
130
150
170
190
SBP @ 5 METs SBP@ 7-METs Peak Exercise
*
mm Hg B-Blockers Other Meds
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LVMI in Normotensive and Hypertensive Women
143
128
117
110
105
99
85
110
135
HTN (+) HTN (-)
*
*
* p<0.01
Kokkinos , Pittaras A et al. Circulation ‘98
g/m2
Low-Fit
Moderate
High-Fit
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Exercise BP, Fitness & LVMI in Men
184
152
135
165
144
117
100
130
160
190
Low-Fit High-Fit
*
*
* p<0.01
Pittaras A, et al. Circulation 2003
EX-BP
ABPM
LVMI
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SBP at 7 METs and LVMI in Fit & Unfit Normotensive Women
160
126
148
103
90
115
140
165
Low-Fit High-Fit
*
*
* p<0.02
Kokkinos P. Pittaras A et al. JACC ‘99
SBP LVMI LVMISBP
*
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SBP at 7 METs and LVMI in Fit & Unfit Hypertensive Women
189
172
143
117
100
130
160
190
SBP LVMI
* * p<0.02
Kokkinos P. Pittaras A et al. JACC ‘99
Low-Fit High-Fit
*
Low-Fit High-Fit
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Exaggerated BP & LVH in Normotensive Men
• Normotensive Men (N=39) • Age: 44.6±8.5• LVH (LVMI >134 g/m2 ) found in
63% (14/22) of those with Peak Exercise SBP >210 mm Hg.
Gottdiener J. et al. Annals Intern Med 1990:112:161-66
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Correlations (r) of Sub-maximal Exercise SBP and ABP (n=892)
5-MET 7-MET r r
Daytime 0.71 0.78
Nighttime 0.69 0.77
24-hours 0.70 0.77
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LVMI & Exercise SBP @ 7-METs in Pre-Hypertensive Women
187
157
133
96
85
110
135
160
185
SBP LVMI
* p<0.01
Normal BP
Ex-HTN
*
*
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LVMI & Exercise SBP @ 7 METs in Pre-Hypertensive Men
80
105
130
155
180
SBP LVMI
* p<0.01 Normal BPEx-HTN
*
*