RESUMEN
Broad evidence indicates that hypertensive response to exercise (HRE) is associated with future hypertension (aHT) at rest and cardiovascular morbidity and mortality. Nevertheless, a consensus on the definition of HRE is lacking and the comparability of the available data is difficult due to a wide variation of definitions used. This review aims to harmonize currently available definitions of HRE in normotensive and athletic populations and to propose a generally valid cut-off applicable in everyday clinical practice. A literature search on PubMed and Embase was conducted to assemble and analyze the most recent data. Various definitions of HRE were identified and linked with future cardiovascular diseases. Forty-one studies defined HRE at a peak systolic blood pressure (SBP) above or equal to 200 mmHg in men and 25 studies for 190 mmHg in women. Peak diastolic blood pressure (DBP) between 90 and 110 mmHg was reported in 14 studies, relative DBP increase in four. Eight studies defined HRE as SBP between 160 and 200 mmHg at 100 watts. 17 studies performed submaximal exercise testing, while two more looked at BP during recovery. A plethora of other definitions was identified. In athletes, total workload and average blood pressure during exercise were considerably higher. Based on the presented data, the most commonly used definition of HRE at peak exercise is 210/105 mmHg for men, 190/105 mmHg for women, and 220/210 mmHg for athletes. Furthermore, a uniform exercise testing protocol, a position statement by leading experts to unify the definition of HRE, and prospective studies are warranted to confirm these cut-offs and the associated morbidity and mortality.
RESUMEN
BACKGROUND & AIMS: Nonselective ß blockers (NSBBs) reduce portal pressure and the risk for variceal hemorrhage in patients with cirrhosis. However, development of spontaneous bacterial peritonitis (SBP) in these patients could preclude treatment with NSBBs because of their effects on the circulatory reserve. We investigated the effects of NSBBs in patients with cirrhosis and ascites with and without SBP. METHODS: We performed a retrospective analysis of data from 607 consecutive patients with cirrhosis who had their first paracentesis at the Medical University of Vienna from 2006 through 2011. Cox models were calculated to investigate the effect of NSBBs on transplant-free survival time and adjusted for Child-Pugh stage and presence of varices. RESULTS: NSBBs increased transplant-free survival in patients without SBP (hazard ratio = 0.75; 95% confidence interval: 0.581-0.968; P = .027) and reduced days of nonelective hospitalization (19.4 days/year for patients on NSBBs vs 23.9 days/year for patients not taking NSBBs). NSBBs had only moderate effects on systemic hemodynamics at patients' first paracentesis. However, at the first diagnosis of SBP, the proportion of hemodynamically compromised patients with systolic arterial pressure <100 mm Hg was higher among those who received NSBBs (38% vs 18% of those not taking NSBBs; P = .002), as was the proportion of patients with arterial pressure <82 mm Hg (64% of those taking NSBBs vs 44% of those not taking NSBBs; P = .006). Among patients with SBP, NSBBs reduced transplant-free survival (hazard ratio = 1.58; 95% confidence interval: 1.098-2.274; P = .014) and increased days of nonelective hospitalization (29.6 days/person-year in patients on NSBBs vs 23.7 days/person-year in those not taking NSBBs). A higher proportion of patients on NSBBs had hepatorenal syndrome (24% vs 11% in those not taking NSBBs; P = .027) and grade C acute kidney injury (20% vs 8% for those not taking NSBBs; P = .021). CONCLUSIONS: Among patients with cirrhosis and SBP, NSBBs increase the proportion who are hemodynamically compromised, time of hospitalization, and risks for hepatorenal syndrome and acute kidney injury. They also reduce transplant-free survival. Patients with cirrhosis and SBP should not receive NSBBs.