Combination of low blood pressure response, low exercise capacity and slow heart rate recovery during an exercise test significantly increases mortality risk

Abstract

Aims: We investigated the combination of low systolic blood pressure (SBP) response, low exercise capacity (EC) and slow heart rate recovery (HRR) during an exercise test in mortality prediction. Patients and methods: Our population consisted of 3456 patients from the Finnish Cardiovascular Study. A failure of SBP to increase >42 mmHg was defined as a low response. Low EC was defined as < 8 metabolic equivalents. 1-minute HRR 18 bpm from maximum was defined as slow HRR. Results: During a median follow up of 10.0 years, 537 participants died. Reduced SBP response, low EC and slow HRR were independent predictors of all-cause and CV mortality (p < .001 for all). Patients with reduced SBP response, low EC and slow HRR had a very high mortality rate of 42.1% during follow up compared to only 4.5% of the patients without any of these risk factors. The hazard ratios for all-cause mortality in patients with one, two or three of the studied risk factors were 3.2, 6.0, and 10.6, respectively (p < .001 for all). Conclusion:The combination of reduced SBP response, low exercise capacity, and reduced HRR in an exercise test is associated with very high mortality and can be used in risk stratification. KEY MESSAGESThe combination of low blood pressure response, low exercise capacity and slow heart rate recovery in an exercise test is able to identify a group of patients in a very high mortality risk. These parameters are easily derived from an exercise test. All parameters are commonly available in clinical practice.

Low but not high exercise systolic blood pressure is associated with long-term all-cause mortality

“…The combined effect of poor exercise capacity and low SBPpeak has previously been shown to be particularly negative for prognosis. 24 Hedman et al 10 and Currie et al 6 have suggested an alternative approach to consider workload in exercise SBP evaluation; the SBP/METslope. This measure index ΔSBP to the increase in METs from rest to peak exercise, and the relation between SBP and the SBP/MET-slope has recently been described in healthy athletes.…”

Typical angina during exercise stress testing improves the prediction of future acute coronary syndrome

“…This study adds to the mountain of evidence of the prognostic information available in exercise stress testing (Cole, et al 1999; Cole & Ellestad, 1978; Daugherty, et al 2011; Forslund, et al 2000; Hedman, et al 2019; Ho, et al 2008; Lindow, et al 2019; Mark, et al 1987; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019; Tsuda, et al 1993; Weiner, et al 1984; Weiner, et al 1986). In the most recent guidelines for management of patients with chronic coronary syndrome, exercise stress testing is no longer recommended as the initial diagnostic test in patients with stable chest pain patients (Knuuti, et al 2019).…”

“…As shown in our study, relying only on ST depression when determining the clinical value of exercise stress testing is inferior to systematically considering additional clinical information such as the occurrence of typical angina. In addition, the SBP response (Hedman, et al 2019; Sipila, et al 2019; Tsuda, et al 1993), exercise capacity (Forslund, et al 2000; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019) and heart rate recovery (Cole, et al 1999; Sipila, et al 2019) have been shown prognostic of future ACS and mortality. In the same cohort, we have previously shown that exercise capacity is strongly associated with both all‐cause and cardiovascular mortality, as well as hospitalization for ischaemic heart disease and heart failure (Lindow, et al 2019).…”

“…In most studies, the diagnostic accuracy of exercise testing is based on ECG criteria alone during exercise and anatomical coronary angiography as the reference standard (Beygui, et al 2000; Chae, et al 1993; Daou, et al 2002; Hecht, et al 1993; Kajinami, et al 1995; Koskinen, et al 1987; Nallamothu, et al 1995). However, exercise stress testing also provides important prognostic information regarding all‐cause mortality, cardiovascular mortality and incident non‐fatal myocardial infarction (AMI) or unstable angina (UA) (Cole, et al 1999; Cole & Ellestad, 1978; Daugherty, et al 2011; Forslund, et al 2000; Hedman, et al 2019; Ho, et al 2008; Lindow, et al 2019; Mark, et al 1987; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019; Weiner, et al 1984; Weiner, et al 1986). Besides ST depression (Mark, et al 1987; Weiner, et al 1984), the systolic blood pressure response during exercise (Hedman, et al 2019; Sipila, et al 2019), chronotropic incompetence (Daugherty, et al 2011; Ho, et al 2008), exercise capacity (Daugherty, et al 2011; Forslund, et al 2000; Lindow, et al 2019; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019) and heart rate recovery (Cole, et al 1999; Sipila, et al 2019) have been found to be associated with future mortality and morbidity.…”

The Chronic Effects of Narghile Use on Males’ Cardiovascular Response During Exercise: A Systematic Review

“…Third, attenuated recovery index is indicative of attenuated HR recovery, which is a marker of cardiac limitation of exercise capacity (Leclerc, 2017). Fourth, HR recovery has been related to higher risk of CVDs, and it is an independent predictor of mortality (Morshedi-Meibodi et al, 2002;Myers et al, 2007;Qiu et al, 2017;Shetler et al, 2001;Sipila et al, 2019). Finally, both attenuated HR at peak exercise and reduced HR recovery were independently associated with cardiovascular mortality (Myers et al, 2007).…”