Stress induced hypertensive response: should it be evaluated more carefully?

Abstract

Various diagnostic methods have been used to evaluate hypertensive patients under physical and pharmacological stress. Several studies have shown that exercise hypertension has an independent, adverse impact on outcome; however, other prognostic studies have shown that exercise hypertension is a favorable prognostic indicator and associated with good outcome. Exercise hypertension may be encountered as a warning signal of hypertension at rest and future hypertensive left ventricular hypertrophy. The results of diagnostic stress tests support that hypertensive response to exercise is frequently associated with high rate-pressure product in hypertensives. In addition to the observations on high rate-pressure product and enhanced ventricular contractility in patients with hypertension, evaluation of myocardial contractility by Doppler tissue imaging has shown hyperdynamic myocardial function under pharmacological stress. These recent quantitative data in hypertensives suggest that hyperdynamic myocardial function and high rate-pressure product response to stress may be related to exaggerated hypertension, which may have more importance than that it has been already given in clinical practice.

Figure 1

Exercise stress echocardiographic images. A: Measurements of left ventricular outflow tract velocities at rest and peak exercise, B: Basal septal tissue systolic velocities at rest and peak exercise, in a hypertensive 53-year-old woman with left ventricular hypertrophy [28].

Figure 2

Dobutamine stress echocardiographic images. Measurements of maximum basal septal tissue systolic velocities at rest and peak stress in a hypertensive patient with basal septal hypertrophy [30].

Figure 3

Enlarged left ventricular cavity after peak exercise. Exercise echocardiogram obtained from an apical four-chamber view of the heart in a 73-year-old woman with a hypertensive response to exercise. An end-systolic image taken immediately after peak exercise (right) shows an enlarged left ventricular (LV) cavity compared with image at rest (left). LA: left atrium; RA: right atrium; RV: right ventricle [39].