Exercise Treadmill Testing in Moderate or Severe Aortic Stenosis: The Left Ventricular Correlates of an Exaggerated Blood Pressure Rise

Abstract

Background Exaggerated blood pressure response during exercise predicts future hypertension and cardiovascular events in general population and different patients groups. However, its clinical and prognostic implications in patients with aortic stenosis have not been previously evaluated. Methods and Results We retrospectively studied 301 patients with moderate to severe asymptomatic aortic stenosis (aged 65±12 years) who underwent echocardiography and a modified Bruce exercise treadmill test. An exaggerated blood pressure response was defined as peak systolic blood pressure ≥190 mm Hg. An abnormal blood pressure response (either blunted or exaggerated) was found in 58% of patients and abnormal left ventricular geometry in 82%. There was no difference in the rates of abnormal blood pressure responses between patients with moderate and severe aortic stenosis ([exaggerated blood pressure response: 21% versus 22%, P =0.876] and [blunted blood pressure response: 35% versus 40%, P =0.647]). Patients with exaggerated blood pressure response (21%) were more likely to be older, have hypertension, higher pretest systolic blood pressure, left ventricular ejection fraction and mass, and increased arterial stiffness (all P <0.05). In a multivariate logistic regression analysis, an exaggerated blood pressure response was associated with higher pulse pressure/stroke volume index (odds ratio 2.45, 95% confidence interval 1.02–6.00, P =0.037) and left ventricular mass (odds ratio 2.04, 95% confidence interval 1.23–3.38, P =0.012) independent of age, hypertension, aortic annulus and left atrium diameter, and left ventricular ejection fraction. Conclusions In those with aortic stenosis, exaggerated blood pressure was strongly related to higher resting blood pressure values, left ventricular mass, and increased arterial stiffness independent of hypertension.

The Physiological Burden of the 6-Minute Walk Test Compared With Cardiopulmonary Exercise Stress Test in Patients With Severe Aortic Stenosis

“… 23 Besides its use for symptomatic status assessment, CPET is used in clinical practice to assess the hemodynamic response to exercise and for prognostic purpose. 23 , 29 Not surprisingly, our data describe a population with a poor prognosis and a very high 1-year risk of hospitalisation as failure to achieve 5 Metabolic equivalents (or V̇O 2 peak ≤ 14 mL/kg/min), and a V̇E/V̇CO 2 slope ≥ 34 during exercise testing is associated with a worse prognosis. 30 , 31 , 32 Therefore, systematic CPET before a valve replacement procedure may be of importance to stratify those high-risk patients in attempt to prioritize patients for surgery.…”

“…Regarding the risk of exhaustion, experts agreed that patients with severe AS should not be excluded from exercise testing since patients probably experienced exhaustion in their everyday lives as documented herein by the 6MWT 23 . Besides its use for symptomatic status assessment, CPET is used in clinical practice to assess the hemodynamic response to exercise and for prognostic purpose 23,29 .…”

Determinants and clinical significance of aortic stiffness in patients with moderate or severe aortic stenosis

“…In keeping with Weisz et al, we did not find any correlation between cf-PWV and trans-aortic flow or with parameters of AS severity. However, our study was larger than that by Weisz et al and presents longer follow-up data, as well as aortic stiffness was derived from cf-PWV which reflects the true biological age of the arteries compared to other methods of evaluating arterial stiffness [19,[23][24][25]. The fact that aortic stiffness is not associated with severity of AS nor with revealed symptoms suggests that the despite similar pathological mechanism there are other important factors (e.g.…”

“…This may reflect the complex haemodynamic interplay between the LV and the afterload imposed by the valvular stenosis, systemic BP and peripheral vascular stiffness. Traditionally, a variety of methods of evaluating systemic arterial stiffness, have been proposed such as echocardiographic measures of systemic arterial stiffness (pulse pressure/stroke volume index) or arterial compliance (stroke volume index/pulse pressure), or velocity vector imaging [19,[23][24][25]. However, the gold standard represents the measurement of aortic stiffness by cf-PWV [20].…”

Arterial Hypertension in Aortic Valve Stenosis: A Critical Update

“…Patients with HT reported increased resting systolic blood pressure (BP) before ETT, an accentuated BP response during ETT and delayed systolic BP regularization following ETT. All of these are known to be related with increased LV mass [ 40 ] and reflect a chronically raised BP overload on the LV and arterial system, necessitating prudent antihypertensive medication optimization to accomplish BP control. In contrast, disclosed symptoms during the ETT are independently related to a lower peak systolic BP and quick early increase in heart rate (HR), both of which are probably triggered by a decline in stroke volume during early exercise and a subsequent inability to rise [ 41 ].…”