ABSTRACT
OBJECTIVE: Exaggerated exercise blood pressure (BP) is independently associated with cardiovascular disease (CVD) outcomes. However, it is unknown how individual CVD risk factors may interact with one another to influence exercise BP. The aim of this study was to quantify direct and indirect associations between CVD risk factors and exercise BP, to determine what CVD risk factor/s most-strongly relate to exercise BP. METHODS: In a cross-sectional design, 660 participants (44 ± 2.6 years, 54% male) from the population-based Childhood Determinants of Adult Health Study had BP measured during low-intensity fixed-workload cycling. CVD risk factors were measured, including body composition, clinic (rest) BP, blood biomarkers, and cardiorespiratory fitness. Associations between CVD risk factors and exercise BP were assessed using linear regression, with direct and indirect pathways of association assessed via structural equation model. RESULTS: Sex, waist-to-hip ratio, fitness, and clinic BP were independently associated with exercise systolic BP (SBP), and along with age, had direct associations with exercise SBP (p < 0.05 all). Most CVD risk factors were indirectly associated with exercise SBP via a relation with clinic BP (p < 0.05 all). Clinic BP, waist-to-hip ratio, and fitness were most-strongly associated (direct and indirect association) with exercise SBP (ß[95% CI]: 9.35 [8.04, 10.67], 4.91 [2.56, 7.26], and -2.88 [-4.25, -1.51] mm Hg/SD, respectively). CONCLUSION: Many CVD risk factors are associated with exercise BP, mostly with indirect effects via clinic BP. Clinic BP, body composition, and fitness were most-strongly associated with exercise BP. These results may elucidate how lifestyle modification could be a primary strategy to decrease exaggerated exercise BP-related CVD risk.
Subject(s)
Cardiovascular Diseases , Hypertension , Adult , Humans , Male , Child , Female , Blood Pressure/physiology , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Cross-Sectional Studies , Risk Factors , Exercise/physiology , Hypertension/epidemiologyABSTRACT
Structured health system-based programs, such as cardiac rehabilitation, may reduce the risk of recurrent stroke. This study aimed to co-design and evaluate a structured program of rehabilitation, developed based on insights from focus groups involving stroke survivors and health professionals. Conducted in Tasmania, Australia in 2019, the 7-week program comprised one hour of group exercise and one hour of education each week. Functional capacity (6 min walk test), fatigue, symptoms of depression (Patient Health Questionnaire), and lifestyle were assessed pre- and post-program, with a historical control group for comparison. Propensity score matching determined the average treatment effect (ATE) of the program. Key themes from the co-design focus groups included the need for coordinated care, improved psychosocial management, and including carers and peers in programs. Of the 23 people approached, 10 participants (70% men, mean age 67.4 ± 8.6 years) completed the program without adverse events. ATE analysis revealed improvements in functional capacity (139 m, 95% CI 44, 234) and fatigue (-5 units, 95% CI -9, -1), with a small improvement in symptoms of depression (-0.8 units, 95% CI -1.8, 0.2) compared to controls. The co-designed program demonstrated feasibility, acceptability, and positive outcomes, suggesting its potential to support stroke survivors.
ABSTRACT
Clinic blood pressure (BP) is recommended for absolute cardiovascular disease (CVD) risk assessment. However, in 'real-world' settings, clinic BP measurement is unstandardised and less reliable compared to more rigorous methods but the impact for absolute CVD risk assessment is unknown. This study aimed to determine the difference in absolute CVD risk assessment using real-world clinic BP compared to standardised BP methods. Participants were patients (n = 226, 59 ± 15 years; 58% female) with hypertension referred to a BP clinic for assessment. 'Real-world' clinic BP was provided by the referring doctor. All participants had unobserved automated office BP (AOBP) and 24-h ambulatory BP monitoring (ABPM) measured at the clinic. Absolute CVD risk was calculated (Framingham) using systolic BP from the referring doctor (clinic BP), AOBP and ABPM, with agreement assessed by Kappa statistic. Clinic systolic BP was 18 mmHg than AOBP and daytime ABPM and 22 mmHg higher than 24-h ABPM (p < 0.001). Subsequently, absolute CVD risk scores using clinic BP were higher compared to AOBP, daytime ABPM and 24-h ABPM (10.4 ± 8.1%, 7.8 ± 6.4%, 7.8 ± 6.3%, and 7.3 ± 6.1%, respectively, P < 0.001). As a result, more participants were classified as high CVD risk using clinic BP (n = 89, 40%) compared with AOBP (n = 44, 20%) daytime ABPM (n = 38, 17%) and 24-h ABPM (n = 38, 17%) (p < 0.001) with weak agreement in risk classification (κ = 0.57[0.45-0.69], κ = 0.52[0.41-0.64] and κ = 0.55[0.43-0.66], respectively). Real-world clinic BP was higher and classified twice as many participants at high CVD risk compared to AOBP or ABPM. Given the challenges to high-quality BP measurement in clinic, more rigorous BP measurement methods are needed for absolute CVD risk assessment.
ABSTRACT
OBJECTIVES: A hypertensive response to submaximal exercise is associated with cardiovascular disease but this relationship is influenced by functional capacity. Spironolactone improves functional capacity, which could mask treatment effects on exercise blood pressure. This study sought to examine this hypothesis. DESIGN: Retrospective analysis of a randomized clinical trial. METHODS: 102 participants (54⯱â¯9â¯years; 52% male) with a hypertensive response to maximal exercise (systolic BP ≥210â¯mmâ¯Hg men; ≥190â¯mmâ¯Hg women) were randomized to 3-month spironolactone 25â¯mg daily (nâ¯=â¯53) or placebo (nâ¯=â¯49). Submaximal exercise blood pressure was measured during low-intensity cycling (50, 60 or 70% age-predicted maximal heart rate). Functional capacity was measured as maximal oxygen capacity obtained during a maximal treadmill exercise test, and (resting) aortic stiffness by carotid-to-femoral pulse wave velocity. RESULTS: Spironolactone improved submaximal exercise systolic blood pressure vs. placebo (-4⯱â¯16 vs. 2⯱â¯15â¯mmâ¯Hg, pâ¯=â¯0.045, Cohen's dâ¯=â¯0.42), and had a small (but non-statistically significant) improvement in functional capacity (0.64⯱â¯5.10 vs. -1.43⯱â¯5.04â¯ml/kg/min, pâ¯=â¯0.06, Cohen's dâ¯=â¯0.4). When treatment effects were expressed as the change in submaximal exercise systolic blood pressure relative to the change in functional capacity, a larger effect size was observed (-0.3⯱â¯1.1 vs. 0.3⯱â¯1.1â¯mmâ¯Hg/ml·kg·min-1, pâ¯=â¯0.01, Cohen's dâ¯=â¯0.58), but was not explained by improved aortic stiffness. CONCLUSIONS: Spironolactone reduces submaximal exercise blood pressure, but this treatment effect may be hidden by improved functional capacity and a non-fixed workload. This highlights the most clinically relevant exercise blood pressure is at a low intensity and fixed workload where the influence of fitness on exercise blood pressure is removed, and the effects of therapy can be appreciated.
Subject(s)
Hypertension , Spironolactone , Blood Pressure , Exercise Test , Female , Humans , Hypertension/drug therapy , Male , Mineralocorticoid Receptor Antagonists/therapeutic use , Pulse Wave Analysis , Retrospective Studies , Spironolactone/therapeutic useABSTRACT
BACKGROUND: A hypertensive response to exercise (HRE) is associated with cardiovascular disease and high blood pressure (BP). A poor cardiovascular risk factor profile may underlie these associations, although this has not been systematically elucidated. Via systematic review and meta-analysis, we aimed to assess the relationship between exercise BP and cardiovascular risk factors, and determine if cardiovascular risk is higher in those with an HRE vs. no-HRE across different study populations (including those with/without high BP at rest). METHODS: Three online databases were searched for cross-sectional studies reporting data on exercise BP, an HRE and cardiovascular risk factors (including arterial structure, lipid, metabolic, inflammatory and kidney function markers). Random-effects meta-analyses and meta-regression were used to calculate pooled correlations between exercise BP and each risk factor and pooled mean differences between those with/without an HRE. RESULTS: Thirty-eight studies (38â295 participants, aged 50â±â3years; 78% male) were included. Exercise SBP was associated with arterial, lipid and kidney function risk markers (Pâ<â0.05). Those with an HRE had greater aortic stiffness (+0.80â±â0.35âm/s), total (+0.14â±â0.03âmmol/l) and low-density lipoprotein (+0.12â±â0.03âmmol/l) cholesterol, triglycerides (+0.24â±â0.04âmmol/l), glucose (+0.15â±â0.05âmmol/l), white blood cell count (+0.49â±â0.16âmmol/l) and albumin-to-creatinine ratio (standardized mean difference: +0.97â±â0.34), and lower flow-mediated dilation (-4.13â±â1.02%) and high-density lipoprotein cholesterol (-0.04â±â0.01âmmol/l) vs. those with no-HRE (Pâ<â0.05 all). Results were broadly similar across study populations. CONCLUSION: Exercise SBP is associated with multiple cardiovascular risk factors, which appear worse in those with an HRE vs. no-HRE. As results were similar across population groups, an HRE should be considered an important indicator of cardiovascular risk.
Subject(s)
Cardiovascular Diseases , Hypertension , Blood Pressure , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Cross-Sectional Studies , Exercise , Female , Humans , MaleABSTRACT
OBJECTIVES: A hypertensive response to exercise (HRE) is associated with cardiovascular disease and high blood pressure (BP). Sub-clinical changes to cardiac structure may underlie these associations, although this has not been systematically determined. Via systematic review and meta-analysis, we aimed to (1) assess the relationship between exercise BP and cardiac structure, and (2) determine if cardiac structure is altered in those with an HRE, across various study populations (including those with/without high BP at rest). DESIGN AND METHODS: Three online databases were searched for cross-sectional studies reporting exercise BP, HRE and cardiac structural variables. Random-effects meta-analyses and meta-regressions were used to calculate pooled correlations between exercise BP and cardiac structure, and pooled mean differences and relative risk between those with/without an HRE. RESULTS: Forty-nine studies, (n=23,707 total; aged 44±4 years; 63% male) were included. Exercise systolic BP was associated with increased left ventricular (LV) mass, LV mass index, relative wall thickness, posterior wall thickness and interventricular septal thickness (p<0.05 all). Those with an HRE had higher risk of LV hypertrophy (relative risk: 2.6 [1.85-3.70]), increased LV mass (47±7g), LV mass index (7±2g/m2), relative wall thickness (0.02±0.005), posterior wall thickness (0.78±0.20mm), interventricular septal thickness (0.78±0.17mm) and left atrial diameter (2±0.52mm) vs. those without an HRE (p<0.05 all). Results were broadly similar between studies with different population characteristics. CONCLUSIONS: Exercise systolic BP is associated with cardiac structure, and those with an HRE show evidence towards adverse remodelling. Results were similar across different study populations, highlighting the hypertension-related cardiovascular risk associated with an HRE.
Subject(s)
Blood Pressure/physiology , Exercise/physiology , Hypertension/physiopathology , Hypertrophy, Left Ventricular/pathology , Hypertrophy, Right Ventricular/pathology , Adult , Aged , Cardiovascular Diseases/physiopathology , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Regression Analysis , Risk , Systole/physiology , Ventricular Remodeling/physiology , Ventricular Septum/physiology , Young AdultABSTRACT
The aim of our study was to estimate the size of regression to the mean with home blood pressure (BP) monitoring and compare with that for office BP. Office and home BP measures were obtained from the BP GUIDE (value of central Blood Pressure for GUIDing managEment for hypertension) study, in which 286 patients had BP measured every 3 months for 12 months. Patients were categorized by 10 mm Hg strata of baseline BP, and regression to the mean measures was calculated for home and office BP. High baseline home BP readings tended to be lower on long-term follow-up, and low baseline readings tended to be higher. For example, patients in the group with mean baseline home systolic BP ≥ 150 mm Hg had a mean baseline systolic BP of 156 mm Hg, which fell to 143 mm Hg at 12 months; and patients in the group with mean baseline home systolic BP < 120 mm Hg had a mean baseline systolic BP of 113 mm Hg which rose to 120 mm Hg at 12 months. Similar patterns were seen in intervention and control groups, and for diastolic BP. The regression dilution ratio for home systolic BP and diastolic BP was 0.52 and 0.64, respectively, compared to 0.40 and 0.55 for office systolic BP and diastolic BP, respectively. Home BP is subject to regression to the mean to a similar degree as office BP. These findings have implications for the diagnosis and management of hypertension using home BP.
Subject(s)
Hypertension , Blood Pressure , Blood Pressure Monitoring, Ambulatory , Humans , Hypertension/diagnosisABSTRACT
Manual measurement of blood pressure (BP) during exercise testing is the recommended standard. Automated measurement of BP is an alternative method used during clinical exercise testing, but there is little data comparing manual and automated BP in this setting. The aim of this study was to determine the concordance between manual and automated BP during a standard clinical treadmill exercise test. 416 participants (66 ± 5 years; 54% male) completed a Bruce treadmill exercise test at baseline or follow-up within a clinical trial of participants with type 2 diabetes mellitus. Manual and automated BP were measured simultaneously at each exercise test stage. Manual BP was measured by a technician blinded to automated BP values (Tango+, Suntech). Concordance between manual and automated BP was assessed using mean differences and intraclass correlations (ICC). Concordance between manual and automated BP across all exercise stages was excellent for systolic BP (overall mean difference: 3 ± 11 mm Hg, P = .598; ICC = 0.964 [95% CI 0.942-0.977] and pulse pressure (overall mean difference: 2 ± 14 mm Hg, P = .595; ICC = 0.934 [95% CI 0.899-0.956]). Concordance between manual and automated diastolic BP across all exercise stages was moderate-to-good (overall mean difference: 1 ± 9 mm Hg, P = .905; ICC = 0.784 [95% CI 0.672-0.858]). Automated BP using the Tango + device is concordant with manual BP during early stages of a standard clinical exercise test. Thus, this automated method may be a suitable alternative to manual measurement of BP during clinical exercise testing.
Subject(s)
Blood Pressure Determination/methods , Diabetes Mellitus, Type 2/physiopathology , Exercise Test/methods , Hypertension/physiopathology , Aged , Auscultation/methods , Automation , Blood Pressure/physiology , Blood Pressure Determination/trends , Exercise/physiology , Female , Humans , Male , Middle Aged , Oxygen Consumption/physiology , Sensitivity and SpecificityABSTRACT
AIMS: To estimate the size of regression to the mean with ambulatory blood pressure (ABP) measurement. METHODS: Participants from five studies who had repeated blood pressure (BP) measurements using office and ambulatory devices were included. Regression to the mean was calculated following participants being grouped by baseline BP categories. Regression dilution ratio was calculated for groups defined by each baseline BP variable. RESULTS: High baseline ABP readings were substantially lower on long-term follow-up, and low baseline readings tended to be higher. Regression to the mean was observed for all ABP parameters; for systolic and diastolic measures; and for intervention and control groups. For example, among those with baseline 24-h SBP of at least 150âmmHg, mean baseline and follow-up BP was 156 and 141âmmHg, respectively; whereas those with baseline 24-h SBP of less than 120âmmHg, mean baseline and follow-up BP was 113 and 119âmmHg, respectively. Regression to the mean was the greatest for night-time ABP. Regression dilution ratios calculated from control groups were 0.52, 0.53, 0.38 and 0.60 for 24-h, daytime, night-time and office SBP, respectively. Similar results were seen for diastolic measures. CONCLUSION: ABP is subject to considerable regression to the mean, which has implications for diagnosis and practise; for example, after initiating treatment for hypertension some of the fall in ABP will be because of regression to the mean. Furthermore, associations of ABP with cardiovascular disease will be substantially underestimated if analyses are not adjusted for regression to the mean, especially for night-time ABP. Replication studies are needed to confirm these findings.
Subject(s)
Blood Pressure Monitoring, Ambulatory/statistics & numerical data , Blood Pressure/physiology , Cardiovascular Diseases , Humans , Regression AnalysisABSTRACT
BACKGROUND: Automated office blood pressure (AOBP) involving repeated, unobserved blood pressure (BP) readings during one clinic visit is recommended for in-office diagnosis and assessment of hypertension. However, the optimal AOBP protocol to determine BP control in the least amount of time with the fewest BP readings is yet to be determined and was the aim of this study. METHODS: One hundred and eighty-nine patients (mean age 62.8 ± 12.1 years; 50.3% female) with treated hypertension referred to specialist clinics at 2 sites underwent AOBP in a quiet room alone. Eight BP measurements were taken starting immediately after sitting and then at 2-minute intervals (15 minutes total). The optimal AOBP protocol was defined by the smallest mean difference and highest intraclass correlation coefficient (ICC) compared with daytime ambulatory BP (ABP). The same BP device (Mobil-o-graph, IEM) was used for both AOBP and daytime ABP. RESULTS: Average 15-minute AOBP and daytime ABP were 134 ± 22/82 ± 13 and 137 ± 17/83 ± 11 mm Hg, respectively. The optimal AOBP protocol was derived within a total duration of 6 minutes from the average of 2 measures started after 2 and 4 minutes of seated rest (systolic BP: mean difference (95% confidence interval) 0.004(-2.21, 2.21) mm Hg, P = 1.0; ICC = 0.81; diastolic BP: mean difference 0.37(-0.90, 1.63) mm Hg, P = 0.57; ICC = 0.86). AOBP measures taken after 8 minutes tended to underestimate daytime ABP (whether as a single BP or the average of more than 1 BP reading). CONCLUSIONS: Only 2 AOBP readings taken over 6 minutes (excluding an initial reading immediately after sitting) may be needed to be comparable with daytime ABP.