Advertisement
Canadian Journal of Cardiology

Prognostic Role of Hypertensive Response to Exercise in Patients With Repaired Coarctation of Aorta

Published:February 07, 2018DOI:https://doi.org/10.1016/j.cjca.2018.02.004

      Abstract

      Background

      This study aimed to determine the prevalence of hypertensive response to exercise (HRE) and its association with cardiovascular adverse events (CAEs) in patients with repaired coarctation of aorta (rCOA).

      Methods

      We retrospectively reviewed records of adult patients with rCOA who had cardiopulmonary exercise tests (CPETs) and follow-up from 1994 to 2014 at Mayo Clinic. Patients with residual COA, defined as aortic isthmus peak velocity >2.5 m/s, were excluded. HRE was defined as peak systolic blood pressure >200 mm Hg; CAEs were defined as cardiovascular death, stroke, acute coronary syndrome, heart failure hospitalization, and left ventricular ejection fraction (LVEF) < 35%.

      Results

      One hundred thirty-eight patients (82 men [59%]) underwent 213 CPETs, with follow-up of 85 ± 13 months. Age at initial COA repair was 9 ± 3 years; age at initial CPET was 40 ± 13 years. HRE occurred in 26 (19%) patients, and 24 (92%) of the patients with HRE had normal resting blood pressure. There were no differences in age, blood pressure at rest, and CPET findings between patients with HRE and those with normotensive response to exercise. There were 28 CAEs in 24 patients (17%), and HRE was an independent risk factor for CAE (hazard ratio [HR], 1.46 [1.13–2.52]; P = 0.04).

      Conclusions

      HRE can occur even in the setting of normal blood pressure at rest, and it is a risk factor for CAE. We speculate that patients with HRE represent a high-risk group of patients who, presumably, have occult, advanced vascular dysfunction. CPET can identify these patients. The benefit of intensive antihypertension therapy needs to be confirmed.

      Résumé

      Contexte

      Cette étude visait à déterminer la prévalence de la réponse hypertensive à l’effort (RHE) ainsi que l’association entre cette réponse et les événements indésirables cardiovasculaires (EIC) chez des patients ayant subi une réparation d’une coarctation de l’isthme aortique (rCOA).

      Méthodologie

      Nous avons effectué un examen rétrospectif des dossiers de patients adultes ayant subi une rCOA, qui avaient été soumis à des épreuves d’effort cardiopulmonaire (EECP) et à un suivi entre 1994 et 2014 à la clinique Mayo. Les patients présentant une COA résiduelle (définie par une vitesse maximale du flux sur l’isthme aortique > 2,5 m/s) ont été exclus. La RHE était définie par une pression artérielle systolique maximale > 200 mm Hg; la définition des EIC comprenait les événements suivants : mortalité cardiovasculaire, AVC, syndrome coronarien aigu, hospitalisation pour insuffisance cardiaque et fraction d’éjection ventriculaire gauche (FEVG) < 35 %.

      Résultats

      Un total de 138 patients (82 hommes [59 %]) ont subi 213 EECP, et leur suivi a duré 85 ± 13 mois. L’âge des patients au moment de la réparation initiale de la COA était de 9 ± 3 ans; au moment des EECP initiaux, leur âge était de 40 ± 13 ans. La RHE est apparue chez 26 (19 %) patients; 24 (92 %) de ces patients étaient normotendus au repos. Aucune différence n'a été observée quant à l’âge, à la pression artérielle au repos et aux résultats des EECP entre les patients présentant une RHE et ceux dont la réponse hypertensive était normale à l’effort. Il s’est produit 28 EIC chez 24 patients (17 %), et la RHE était un facteur de risque indépendant d’EIC (rapport des risques instantanés [RRI]: 1,46 [1,13-2,52]; p = 0,04).

      Conclusion

      La RHE peut apparaître même chez les sujets normotendus au repos, et constitue un facteur de risque d’EIC. Selon notre hypothèse, les patients obtenant une RHE représentent un groupe à risque élevé qui, vraisemblablement, sont atteints d’une dysfonction vasculaire avancée occulte. Les EECP pourraient permettre de reconnaître ces patients. L’avantage du traitement antihypertensif énergique reste à confirmer.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rosenthal E.
        Coarctation of the aorta from fetus to adult: curable condition or life long disease process?.
        Heart. 2005; 91: 1495-1502
        • Krieger E.V.
        • Stout K.
        The adult with repaired coarctation of the aorta.
        Heart. 2010; 96: 1676-1681
        • Egbe A.
        • Uppu S.
        • Stroustrup A.
        • Lee S.
        • Ho D.
        • Srivastava S.
        Incidences and sociodemographics of specific congenital heart diseases in the United States of America: an evaluation of hospital discharge diagnoses.
        Pediatr Cardiol. 2014; 35: 975-982
        • Brown M.L.
        • Burkhart H.M.
        • Connolly H.M.
        • Dearani J.A.
        • Hagler D.J.
        • Schaff H.V.
        Late outcomes of reintervention on the descending aorta after repair of aortic coarctation.
        Circulation. 2010; 122: S81-S84
        • Brown M.L.
        • Burkhart H.M.
        • Connolly H.M.
        • et al.
        Coarctation of the aorta: lifelong surveillance is mandatory following surgical repair.
        J Am Coll Cardiol. 2013; 62: 1020-1025
        • de Divitiis M.
        • Pilla C.
        • Kattenhorn M.
        • et al.
        Ambulatory blood pressure, left ventricular mass, and conduit artery function late after successful repair of coarctation of the aorta.
        J Am Coll Cardiol. 2003; 41: 2259-2265
        • de Divitiis M.
        • Pilla C.
        • Kattenhorn M.
        • et al.
        Vascular dysfunction after repair of coarctation of the aorta: impact of early surgery.
        Circulation. 2001; 104: I165-I170
        • Daniels S.R.
        • James F.W.
        • Loggie J.M.
        • Kaplan S.
        Correlates of resting and maximal exercise systolic blood pressure after repair of coarctation of the aorta: a multivariable analysis.
        Am Heart J. 1987; 113: 349-353
        • James F.W.
        • Kaplan S.
        Systolic hypertension during submaximal exercise after correction of coarctation of aorta.
        Circulation. 1974; 50: II27-II34
        • Egbe A.C.
        • Driscoll D.J.
        • Khan A.R.
        • et al.
        Cardiopulmonary exercise test in adults with prior Fontan operation: the prognostic value of serial testing.
        Int J Cardiol. 2017; 235: 6-10
        • Diller G.P.
        • Dimopoulos K.
        • Okonko D.
        • et al.
        Heart rate response during exercise predicts survival in adults with congenital heart disease.
        J Am Coll Cardiol. 2006; 48: 1250-1256
        • Astrand I.
        Aerobic work capacity in men and women with special reference to age.
        Acta Physiol Scand Suppl. 1960; 49: 1-92
        • Lauer M.S.
        • Levy D.
        • Anderson K.M.
        • Plehn J.F.
        Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study.
        Ann Intern Med. 1992; 116: 203-210
        • Fletcher G.F.
        • Ades P.A.
        • Kligfield P.
        • et al.
        • American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention
        Exercise standards for testing and training: a scientific statement from the American Heart Association.
        Circulation. 2013; 128: 873-934
        • Egbe A.C.
        • Connolly H.M.
        • Niaz T.
        • et al.
        Prevalence and outcome of thrombotic and embolic complications in adults after Fontan operation.
        Am Heart J. 2017; 183: 10-17
        • Egbe A.C.
        • Warnes C.A.
        Cardiovascular adverse events after aortic valve replacement in mixed aortic valve disease: beyond ejection fraction.
        J Am Coll Cardiol. 2016; 68: 2591-2593
        • Rinnstrom D.
        • Dellborg M.
        • Thilen U.
        • et al.
        Hypertension in adults with repaired coarctation of the aorta.
        Am Heart J. 2016; 181: 10-15
        • Wu M.H.
        • Chen H.C.
        • Kao F.Y.
        • Huang S.K.
        Risk of systemic hypertension and cerebrovascular accident in patients with aortic coarctation aged <60 years (from a National Database Study).
        Am J Cardiol. 2015; 116: 779-784
        • de Divitiis M.
        • Rubba P.
        • Calabro R.
        Arterial hypertension and cardiovascular prognosis after successful repair of aortic coarctation: a clinical model for the study of vascular function. Nutr, Metab.
        Cardiovasc Dis. 2005; 15: 382-394
        • Correia A.S.
        • Goncalves A.
        • Paiva M.
        • et al.
        Long-term follow-up after aortic coarctation repair: the unsolved issue of exercise-induced hypertension.
        Rev Port Cardiol. 2013; 32: 879-883
        • Luijendijk P.
        • Bouma B.J.
        • Vriend J.W.
        • Vliegen H.W.
        • Groenink M.
        • Mulder B.J.
        Usefulness of exercise-induced hypertension as predictor of chronic hypertension in adults after operative therapy for aortic isthmic coarctation in childhood.
        Am J Cardiol. 2011; 108: 435-439
        • Thanassoulis G.
        • Lyass A.
        • Benjamin E.J.
        • et al.
        Relations of exercise blood pressure response to cardiovascular risk factors and vascular function in the Framingham Heart Study.
        Circulation. 2012; 125: 2836-2843
        • Lim P.O.
        • MacFadyen R.J.
        • Clarkson P.B.
        • MacDonald T.M.
        Impaired exercise tolerance in hypertensive patients.
        Ann Intern Med. 1996; 124: 41-55
        • Lee M.G.Y.
        • Hemmes R.A.
        • Mynard J.
        • et al.
        Elevated sympathetic activity, endothelial dysfunction, and late hypertension after repair of coarctation of the aorta.
        Int J Cardiol. 2017; 243: 185-190
        • Warnes C.A.
        • Williams R.G.
        • Bashore T.M.
        • et al.
        ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2008; 52: e143-e263
        • Baumgartner H.
        • Bonhoeffer P.
        • De Groot N.M.
        • et al.
        • Task Force on the Management of Grown-up Congenital Heart Disease of the European Society of Cardiology (ESC); Association for European Paediatric Cardiology (AEPC); ESC Committee for Practice Guidelines (CPG)
        ESC Guidelines for the management of grown-up congenital heart disease (new version 2010).
        Eur Heart J. 2010; 31: 2915-2957

      Linked Article