Evaluation of myocardial microcirculation in patients with hypertensive responses after exercise by treadmill exercise stress echocardiography and myocardial contrast echocardiography

doi:10.3877/cma.j.issn.1672-6448.2019.10.005

Abstract

Abstract:

Objective

To evaluate the effect of hypertensive responses (HRE) on myocardial function by treadmill exercise stress echocardiography (ESE) and myocardial contrast echocardiography (MCE).

Methods

Thirty-two patients with HRE were enrolled as an HRE group and 28 adults with negative stress echocardiography results were included as a control group from January 2017 to December 2018 at Sichuan Provincial People′s Hospital. Treadmill ESE combined with MCE were used to acquire the 2D and myocardial perfusion images at baseline and after exercises. The exercise capacity, blood pressure (BP), left atria (LA) and left ventricle (LV) volume, relative wall thickness (RWT), LV systolic function, LV diastolic function, and myocardial perfusion parameters during different stages were compared between the two groups.

Results

At baseline, the E/e' in the HRE group was significantly higher than that in the control group (t=3.018, P<0.05). The exercise tolerance parameter (METs) in the HRE group was significantly lower than that in the control group (t=4.786, P<0.01). In the HRE group, ST-segment depression≥ 0.1 mV with level/down-slope type appeared in 10 cases, and none of the control group showed ST-segment changes (χ²=24.97, P<0.01). One subject had atrial premature heartbeat in the control group, while there were five cases of atrial/ventricular premature heartbeat in the HRE groups; there was a statistically significant difference between the two groups (χ²=21.45, P<0.05). The peak SBP in the HRE group was significantly higher than that in the control group (t=2.131, P<0.05). Wall motion abnormalities were observed in six cases in the HRE group, while there was no wall motion abnormalities in the control group (χ²=18.58, P<0.05). e′ and E/e′ after exercise were significantly higher in cases than in controls (t=2.472 and 3.018, respectively, P<0.05). At baseline, there was no significant difference in myocardial blood flow velocity (k), peak intensity (A), or myocardial blood flow (MBF) between the two groups (P>0.05). Immediately after exercise, the k, A, and MBF of the subendocardial myocardium in the HRE group were significantly lower than those of the control group (t=3.692, 2.582, and 4.673, respectively, P<0.05). There was no significant difference in the subepicardial myocardium perfusion parameter A between the two groups (P>0.05). The k and MBF values in the subepicardial myocardium in the HRE group were significantly lower those of the control group (t=3.147 and 2.375, respectively, P<0.05). We also compared the perfusion parameters between the six subjects with low wall motion and the other 26 subjects with normal wall motion in the HRE group. We found that k, A, and MBF of the subendocardial myocardium after exercise were significantly lower in the low wall motion group (t=3.487, 2.453, and 4.298, respectively, P<0.05).

Conclusion

LV diastolic function is significantly reduced in patients with HRE, and myocardial perfusion, especially subendocardial myocardial microcirculation, is significantly impaired. Treadmill ESE is a simple, non-invasive method for assessing cardiac function, and it can be used to early detect myocardial microcirculation dysfunction in HRE patients with normal rest conventional echocardiography images if combined with MCE. These two combined techniques might have important value in early diagnosis and long-term follow-up of cardiac dysfunction in HRE patients.

Key words: Echocardiography, Myocardial contrast echocardiography, Exercise test, Hypertension, Microcirculation

Yi Wang, Zhiyu Guo, Hongmei Zhang, Qingfeng Zhang, Geqi Ding, Lixue Yin. Evaluation of myocardial microcirculation in patients with hypertensive responses after exercise by treadmill exercise stress echocardiography and myocardial contrast echocardiography[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2019, 16(10): 735-741.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://chaosheng.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1672-6448.2019.10.005

https://chaosheng.cma-cmc.com.cn/EN/Y2019/V16/I10/735

Figures/Tables 5

References 27

[1]	Itoh H, Ajisaka R, Koike A, et al. Heart rate and blood pressure response to ramp exercise and exercise capacity in relation to age, gender, and mode of exercise in a healthy population [J]. J Cardiol, 2013, 61(1): 71-78.
[2]	Mancia G, Faggard R, Narkiewicz K, et al. 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension [J]. J Hypertens, 2013, 31(10): 1925-1938.
[3]	Schultz MG, La Gerche A, and Sharman JE. Blood Pressure Response to Exercise and Cardiovascular Disease [J]. Curr Hypertens Rep, 2017, 19(11): 89.
[4]	Sun L, Wang Z, Xu T, et al. The value of real-time myocardial contrast echocardiography for detecting coronary microcirculation function in coronary artery disease patients [J]. Anatol J Cardiol, 2018, 19(1): 27-33.
[5]	Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association [J]. Circulation, 2005, 111(5): 682-696.
[6]	Tzemos N, Lim PO, Mackenzie IS, et al. Exaggerated Exercise Blood Pressure Response and Future Cardiovascular Disease [J]. J Clin Hypertens (Greenwich), 2015, 17(11): 837-844.
[7]	Stewart KJ, Sung J, Silber HA, et al. Exaggerated exercise blood pressure is related to impaired endothelial vasodilator function [J]. Am J Hypertens, 2004, 17(4): 314-320.
[8]	Thanassoulis G, Lyass A, Benjamin EJ, et al. Relations of exercise blood pressure response to cardiovascular risk factors and vascular function in the Framingham Heart Study [J]. Circulation, 2012, 125(23): 2836-2843.
[9]	Schultz MG, Otahal P, Cleland VJ, et al. Exercise-induced hypertension, cardiovascular events, and mortality in patients undergoing exercise stress testing: a systematic review and meta-analysis [J]. Am J Hypertens, 2013, 26(3): 357-366.
[10]	Manolio TA, Burke GL, Savage PJ, et al. Exercise blood pressure response and 5-year risk of elevated blood pressure in a cohort of young adults: the CARDIA study [J]. Am J Hypertens, 1994, 7(3): 234-241.
[11]	Youn JC, Kang SM. Cardiopulmonary Exercise Test in Patients with Hypertension: Focused on Hypertensive Response to Exercise [J]. Pulse (Basel), 2015, 3(2): 114-117.
[12]	Fagard RH, Pardaens K, Staessen JA, et al. Prognostic value of invasive hemodynamic measurements at rest and during exercise in hypertensive men [J]. Hypertension, 1996, 28(1): 31-36.
[13]	Vigil Medina L, Garcia Carretero R. Hypertensive response to exercise: Does it has prognostic implications? [J]. Rev Clin Esp, 2019. [Epub ahead of print].
[14]	Takamura T, Onishi K, Sugimoto T, et al. Patients with a hypertensive response to exercise have impaired left ventricular diastolic function [J]. Hypertens Res, 2008, 31(2): 257-263.
[15]	Kim D, Ha JW. Hypertensive response to exercise: mechanisms and clinical implication [J]. Clin Hypertens, 2016, 22: 17.
[16]	Shim CY, Ha JW, Park S, et al. Exaggerated blood pressure response to exercise is associated with augmented rise of angiotensin II during exercise [J]. J Am Coll Cardiol, 2008, 52(4): 287-292.
[17]	Mottram PM, Haluska B, Yuda S, et al. Patients with a hypertensive response to exercise have impaired systolic function without diastolic dysfunction or left ventricular hypertrophy [J]. J Am Coll Cardiol, 2004, 43(5): 848-853.
[18]	Lauer MS, Levy D, Anderson KM, et al. Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study [J]. Ann Intern Med, 1992, 116(3): 203-210.
[19]	Shim CY, Hong GR, Park S, et al. Impact of central haemodynamics on left ventricular function in individuals with an exaggerated blood pressure response to exercise [J]. J Hypertens, 2015, 33(3): 612-620.
[20]	Bozbas H, Pirat B, Yildirir A, et al. Coronary microvascular function in patients with isolated systolic and combined systolic/diastolic hypertension [J]. J Clin Hypertens (Greenwich), 2012, 14(12): 871-876.
[21]	Erdogan D, Yildirim I, Ciftci O, et al. Effects of normal blood pressure, prehypertension, and hypertension on coronary microvascular function [J]. Circulation, 2007, 115(5): 593-599.
[22]	Ha JW, Juracan EM, Mahoney DW, et al. Hypertensive response to exercise: a potential cause for new wall motion abnormality in the absence of coronary artery disease [J]. J Am Coll Cardiol, 2002, 39(2): 323-327.
[23]	Fletcher GF, Balady G, Froelicher VF, et al. Exercise standards. A statement for healthcare professionals from the American Heart Association. Writing Group [J]. Circulation, 1995, 91(2): 580-615.
[24]	Detrano R, Froelicher VF. Exercise testing: uses and limitations considering recent studies [J]. Prog Cardiovasc Dis, 1988, 31(3): 173-204.
[25]	Jang JY, Sohn IS, Kim JN, et al. Treadmill exercise stress echocardiography in patients with no history of coronary artery disease: a single-center experience in korean population [J]. Korean Circ J, 2011, 41(9): 528-534.
[26]	Vrints CJ. Refined interpretation of exercise ECG testing: Opportunities for a comeback in the era of expanding advanced cardiac imaging technologies? [J]. Eur J Prev Cardiol, 2016, 23(15): 1628-1631.
[27]	Feher A, Sinusas AJ. Quantitative Assessment of Coronary Microvascular Function: Dynamic Single-Photon Emission Computed Tomography, Positron Emission Tomography, Ultrasound, Computed Tomography, and Magnetic Resonance Imaging [J]. Circ Cardiovasc Imaging, 2017, 10(8).

临床资料	HRE组（32例）	对照组（28例）	统计值	P值
年龄（岁）	52.3±7.9	50.5±6.8	t=0.523	0.71
性别（例，男/女）	18/14	15/13	χ²=6.11	0.75
BMI（kg/m²）	22.54±1.87	22.32±1.72	t=0.313	0.88
基线SBP（mmHg）	123±16	120±13	t=0.659	0.56
基线DBP（mmHg）	65±9	61±6	t=0.612	0.67
心率（次/分）	70±6	68±5	t=0.512	0.78

临床资料	HRE组（32例）	对照组（28例）	统计值	P值
年龄（岁）	52.3±7.9	50.5±6.8	t=0.523	0.71
性别（例，男/女）	18/14	15/13	χ²=6.11	0.75
BMI（kg/m²）	22.54±1.87	22.32±1.72	t=0.313	0.88
基线SBP（mmHg）	123±16	120±13	t=0.659	0.56
基线DBP（mmHg）	65±9	61±6	t=0.612	0.67
心率（次/分）	70±6	68±5	t=0.512	0.78

参数	HRE组（32例）	对照组（28例）	t值	P值
LVEDV（ml）	80±21	78±20	0.521	0.61
LAVI（ml/m²）	36.5±10.3	33.2±9.5	0.537	0.57
RWT	0.35±0.06	0.33±0.04	0.598	0.51
LVEF（%）	63±8	61±9	0.630	0.49
E（cm/s）	65.5±13.2	68.7±15.5	0.750	0.39
A（cm/s）	66.7±14.8	69.2±14.6	0.715	0.42
E/A	0.98±0.10	0.99±0.12	0.439	0.87
e′（cm/s）	6.2±0.9	8.1±1.0	1.087	0.21
a′（cm/s）	9.7±2.4	9.6±2.5	0.496	0.76
E/e′	10.56±1.37	8.48±1.25	3.018	<0.05

参数	HRE组（32例）	对照组（28例）	t值	P值
LVEDV（ml）	80±21	78±20	0.521	0.61
LAVI（ml/m²）	36.5±10.3	33.2±9.5	0.537	0.57
RWT	0.35±0.06	0.33±0.04	0.598	0.51
LVEF（%）	63±8	61±9	0.630	0.49
E（cm/s）	65.5±13.2	68.7±15.5	0.750	0.39
A（cm/s）	66.7±14.8	69.2±14.6	0.715	0.42
E/A	0.98±0.10	0.99±0.12	0.439	0.87
e′（cm/s）	6.2±0.9	8.1±1.0	1.087	0.21
a′（cm/s）	9.7±2.4	9.6±2.5	0.496	0.76
E/e′	10.56±1.37	8.48±1.25	3.018	<0.05

超声心动图参数	HRE组（32例）	对照组（28例）	统计值	P值
运动时间（ min）	6.9±0.9	7.5±1.5	t=0.637	0.48
METs	7.8±1.6	10.3±2.1	t=4.786	<0.01
峰值HR（%，目标HR）	86±7	90±10	t=0.852	0.29
恢复时间（min）	7.2±2.3	5.1±1.1	t=0.837	0.30
ST段改变（例）	10/32	0/28	χ²=24.97	<0.01
其他心律失常（例）	5/32	1/28	χ²=21.45	<0.05
峰值SBP（mmHg）	203±20	186±21	t=2.131	<0.05
峰值DBP（mmHg）	75±17	73±13	t=0.747	0.38
运动后LVEF（%）	88±9	85±8	t=0.852	0.31
心室壁运动异常（例）	6/32	0/28	χ²=18.58	<0.05
运动后E（cm/s）	97.6±16.2	98.5±17.5	t=0.732	0.41
运动后A（cm/s）	72.7±14.8	70.2±14.6	t=0.741	0.39
运动后E/A	1.34±0.14	1.40±0.17	t=0.512	0.61
运动后e′（cm/s）	5.7±0.6	9.2±1.2	t=2.472	<0.05
运动后a′（cm/s）	11.5±2.7	10.2±2.8	t=0.627	0.27
运动后E/e′	17.12±3.56	10.71±2.16	t=3.018	<0.05

Please choose a citation manager

Content to export