Abstract
Early determination of changes in myocardial functions is essential for the protection of cardiovascular diseases. This study aimed to evaluate myocardial work parameters in healthy individuals who developed an exaggerated hypertensive response during the treadmill exercise test procedure. The study included a total of 64 patients for whom an exercise electrocardiography test was planned for functional capacity evaluation. The study population was divided according to the presence of exaggerated hypertensive response to exercise (EBPRE) (SBP/DBP ≥210/105 mmHg in males ≥190/105 mmHg in females) and normal blood pressure response to exercise (NBPRE). Patients’ echocardiographic evaluations were made at rest, and myocardial work parameters were calculated. There was no statistical difference between the groups (NBPRE vs. EBPRE, respectively) in terms of left ventricular 2,3 and 4 chamber strains and global longitudinal strain (GLS) values (−20.6 ± −2.3, −19.7 ± −1.9, p:.13; −21.3 ± −2.7, −21 ± −2.4, p:.68; −21.2 ± −2.2, −21.2 ± −2.3, p:.93; and −20.8 ± −1.5, −20.4 ± −1.5, p:.23, respectively). Global constrictive work (GCW), global waste work (GWW), and global work efficiency (GWE) were not statistically different between the two groups (2374 ± 210, 2465 ± 204, p:.10; 142 ± 64, 127 ± 42, p:.31; 94.3 ± 2.5, 95.1 ± 1.5, p:.18, respectively). In contrast, global work index (GWI) parameters were different between the two groups (2036 ± 149, 2147 ± 150, p < .001). The GWI was independently associated with EBPRE (odds ratio with 95% 3.32 (1.02‐11.24), p = .03). The partial effect plots were used for GWI to predict EBPRE, according to the results, an increase in GWI predicts probability of exaggerated hypertensive response. In conclusion, Myocardial work analyses might be used to identify early signs of myocardial involvement in normotensive patients with EBPRE.
Keywords: echocardiography, hypertension, hypertensive response exercise, myocardial work index, Myocardial work parameters
1. INTRODUCTION
In recent years, parameters of myocardial deformation have been used frequently in echocardiographic evaluations because they provide more detailed information. It is known that left ventricular (LV) global longitudinal strain (GLS) assessment is superior to LV ejection fraction (EF) for LV function assessment. 1 However, LV‐GLS has several limitations, the most important limitation of strain evaluation is that it is load‐dependent and does not provide information about myocardial efficiency. Russel and colleagues developed a non‐invasive method that can obtain myocardial work measurements by using strain echocardiography parameters and blood pressure values; they also showed that myocardial work values were compatible with myocardial glucose metabolism. 2 , 3 Since the measurements made in the evaluation of myocardial work are not load‐dependent. Several studies reported the use of myocardial work measurements in cardiac resynchronization therapy (CRT) candidates, as well as patients suffering from coronary artery diseases (CAD), cardiomyopathies, and heart failure. 4 , 5 , 6 , 7
In the daily practice of cardiology, stress electrocardiography tests have been used for years to investigate ischemia and determine functional capacity at out‐patient clinics. 8 During stress electrocardiography, an increase in arterial systolic pressure is expected in both hypertensive and normotensive individuals. However, this hypertensive response to exercise is exaggerated in some patients (defined as systolic blood pressure/diastolic blood pressure ≥210/105 mmHg in males and ≥190/105 mmHg in females respectively). 9 , 10 In addition, the frequency of being diagnosed with hypertension throughout life is higher in individuals who develop an exaggerated hypertensive response to exercise (EBPRE), and also cardiovascular risk is increased in patients who develop a hypertensive response during exercise. 11 , 12 , 13 , 14 , 15 Some studies investigated impairment in myocardial tissue deformation parameters, diastolic function, and strain parameters in individuals who developed hypertensive responses to exercise. 16 , 17 , 18
In order to prevent and treat cardiovascular diseases, it is essential to detect deterioration in myocardial function at an early stage. There is no recommendation for further investigation in individuals with EBPRE detected on electrocardiographic stress test results. The aim of our study was to investigate whether myocardial work analysis can provide information about myocardial involvement in normotensive individuals with exaggerated blood pressure response to exercise stress testing.
2. METHODS
In this study, we included a total of 64 patients for whom an exercise electrocardiography test was planned for functional evaluation between November 2019 and May 2020. As the consort diagram (Figure 1) shows, 22 individuals developed an EBPRE and 42 individuals developed a normal hypertensive response enrolled in the study.
FIGURE 1.
Consort flow diagram of patients’ inclusion and exclusion criteria.
We included patients aged over 18 years with normal tension arterial values before the exercise electrocardiography stress test (<120/80). The exclusion criteria were as follows: having a history of CAD, diabetes mellitus (DM), and hypertension; using drugs affecting arterial tension measurements; patients with atrial fibrillation; patients with renal failure or hepatic disorders; taking steroids or any kind of hypertensive treatments; patients with evidence of myocardial ischemia during treadmill exercise testing; patients with METs score less than 7 during treadmill exercise testing and failure to reach target heart rate (85% of target HR); patients with inadequate echocardiographic image quality (2‐, 3‐, and 4‐chamber views); patients with abnormal baseline left ventricular ejection function (EF < 50%); patients with LV hypertrophy detected by echocardiography; patients with more than mild valvular disease; and patients with diastolic dysfunction detected by echocardiography.
Anthropometric and laboratory data of all participants were collected from the hospital databases. All patients signed informed consent and the study was approved by the local research ethics committee.
2.1. chocardiographic evaluation
An echocardiography evaluation was performed using the Vivid 7 ultrasound machine (GE Healthcare). In 2D imaging, LV cavity and wall thicknesses and left atrial dimensions of the patients were measured, and diastolic dysfunction was evaluated by pulse wave and tissue Doppler methods. LV EF was evaluated using Simpson's biplane method. In echocardiographic evaluation, 4‐cavity, 3‐cavity, and 2‐chamber images were taken and used in strain analysis and myocardial work analysis. 19 , 20 , 21
Myocardial work parameters were calculated by using off‐line Echo Pac software with version 202 (General Electric Medical Systems). The software algorithm was based on estimating left ventricular pressure throughout the cardiac cycle, with a reference curve that was scaled to user‐specified valve closure times using measured blood pressure values. Using the estimated LV pressure and strain assessment, the generated pressure strain curves were used for myocardial work assessment. Global Myocardial work index (GWI), global myocardial constructive work (GCW), global myocardial waste work (GWW), and global myocardial work efficiency (GWE) (calculated by dividing GCW by the sum of GCW and GWW) parameters were calculated. The approximate normal values of the parameters were obtained according to the data obtained from the previous studies: global GWI 1900 mmHg_%; global GCW 2200 mmHg_%; global GWW 80−90 mmHg_%; and the global GWE 96.5%. global GWI was slightly higher in women, and it increased with the elderly. Less than 5% of the work done was wasted in normal hearts 22 (Figure 2).
FIGURE 2.
Myocardial strain and myocardial work parameters analysis results.
2.2. Electrocardiographic stress test
The subjects underwent a graded symptom‐limited maximum treadmill exercise test using the modified Bruce protocol. Electrocardiography, HR, and blood pressure measurements were monitored every minute throughout the study. EBPRE was defined as SBP/DBP ≥210/105 mmHg in males and ≥190/105 mmHg in females at the end of a 6‐min (7 METs) treadmill exercise test using the modified Bruce protocol. 12
2.3. Statistical analysis
Continuous variables were presented with mean (SD) and discrete variables were represented with count and percentage. In addition, the comparison of continuous and discrete variables was done using the t‐test and χ 2 test, respectively. Normal distribution was verified using the Kolmogorov–Smirnov test and visual assessment of the histogram. Meanwhile, the Mann–Whitney U test was utilized for non‐normal variables. Response variables were exaggerated HRE Predictor variables and regression modeling
We used multivariable logistic regression analysis, in which the alpha was set as 0.25. In the multivariable logistic regression of our model‐1 and model‐2, 3 candidate predictors were; mitral A wave, GWI, and GCW, the model 1 retained variables with GLS. While the second model added GWI instead of GLS.
The model's performance comparison was made with a likelihood ratio of χ 2. Models were compared with the assessment of fit (likelihood ratio chi‐square), and predictive accuracy of adjusted‐R2. The added variable plot was used for the demonstration of variables (GWI, GLS) in regression models
In addition, to find the optimal cut‐off point for GWI, we used the ROC curve analysis and class variable as an abnormal response of the treadmill test. A p < .05 was set as significant.
3. RESULTS
The participants were divided into two groups non‐EBPRE (n = 42) and EBPRE (n = 22). The mean age of patients was not statistically different between the two groups (47.2 ± 11.4 vs. 45.1 ± 10.3; p:.47). Sex, height, weight, body surface area (BSA), and laboratory parameters of patients were not statistically different between the two groups (Table 1). Resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) of patients were similar (109 ± 5.2, 111 ± 5.0, p:.13 vs. 69.2 ± 4.9, 67.4 ± 4.2, p:.18, respectively). There was no statistical difference between the Non‐EBPRE and EBPRE groups by means of the measurement's cardiac chambers, LV walls, and LV mass. Also, there was no statistical difference in tissue Doppler recordings. Other parameters are presented in Table 1. There was no statistical difference between the groups in terms of LV 3‐chamber, 2‐chamber, and 4‐chamber strains and GLS values (−20.6 ± −2.3, −19.7 ± −1.9, p:.13; −21.3 ± −2.7, −21 ± −2.4, p:.68; −21.2 ± −2.2, −21.2 ± −2.3, p:.93; and −20.8 ± −1.5, −20.4 ± −1.5, p:.23, respectively).
TABLE 1.
Demographic, laboratory, and echocardiographic parameters of patients.
| Variable | NBPRE group (n:42) | EBPRE group (n:22) | All group (n:64) | p |
|---|---|---|---|---|
| Age (years) | 47.2 ± 11.4 | 45.1 ± 10.3 | 46.5 ± 11 | .47 |
| Sex (male %) | 32 (78) | 18 (81.8) | 50 (79.4) | .72 |
| Height (cm) | 165 ± 8.5 | 168 ± 8.4 | 166 ± 8.5 | .22 |
| Weight (kg) | 82 ± 12.5 | 81 ± 14.3 | 81.5 ± 13 | .73 |
| BSA (m2) | 1.9 ± 0.2 | 1.9 ± 0.2 | 1.9 ± 0.2 | .94 |
| Systolic blood pressure (mmHg) rest in echocardiography | 109 ± 5.2 | 111 ± 5.0 | 110 ± 5.2 | .13 |
| Diastolic blood pressure (mmHg) rest in echocardiography | 69.2 ± 4.9 | 67.4 ± 4.2 | 68.6 ± 4.8 | .18 |
| Peak systolic blood pressure in exercise electrocardiography (mmHg) | 181.4 ± 12.2 | 211.8 ± 8.4 | 194.2 ± 20.8 | <.001 |
| Peak diastolic blood pressure in exercise electrocaerdiography (mmHg) | 79.2 ± 4.9 | 77.4 ± 4.2 | 78.6 ± 4.8 | .18 |
| Hemoglobin (g/dL) | 12.4 ± 1.9 | 12.9 ± 2.5 | 12.6 ± 2.2 | .45 |
| Platelete (109/L) | 244 ± 75 | 275 ± 80 | 255 ± 78 | .15 |
| Neutrophile (×103/µL) | 5.9 ± 2.4 | 6 ± 2.0 | 6 ± 2.3 | .91 |
| Creatinine (mg/dL) | 0.8 ± 0.2 | 0.9 ± 0.2 | 0.8 ± 0.2 | .76 |
| Urea (mg/dL) | 36 ± 9.5 | 39 ± 16 | 37 ± 12.5 | .33 |
| GFR (mL/min/1.73 m2) | 89 ± 15 | 87 ± 20 | 88 ± 20 | .72 |
| Na (mEq/L) | 139 ± 2.1 | 139 ± 2.4 | 139 ± 2.2 | .69 |
| K (mmol/L) | 4.02 ± 0.89 | 4.18 ± 0.68 | .069 | |
| ESD (mm) | 29.5 ± 3.6 | 28.7 ± 3.8 | 29.2 ± 3.7 | .39 |
| EDD (mm) | 48 ± 4.1 | 48.4 ± 5.9 | 48.2 ± 4.7 | .77 |
| IVS (mm) | 0.99 ± 0.17 | 0.97 ± 0.14 | 0.98 ± 0.16 | .68 |
| PW (mm) | 0.96 ± 0.15 | 0.96 ± 0.12 | 0.96 ± 0.14 | .94 |
| Pulmonary velocity (cm/s) | 1.1 ± 0.2 | 1.2 ± 0.2 | 1.2 ± 0.2 | .20 |
| Aortic velocity (cm/s) | 1.3 ± 0.2 | 1.4 ± 0.3 | 1.3 ± 0.3 | .21 |
| LV mass (g) | 167 ± 41 | 168 ± 47 | 167 ± 43 | .91 |
| LV mass index (g/m2) | 87.1 ± 24.4 | 87.5 ± 26.8 | 87.2 ± 25.1 | .95 |
| LaD (mm) | 33.1 ± 3.9 | 34.4 ± 4 | 33.6 ± 3.9 | .23 |
| E (m/s) | 0.8 ± 0.2 | 0.7 ± 0.2 | 0.7 ± 0.2 | .42 |
| A (m/s) | 0.8 ± 0.2 | 0.9 ± 0.2 | 0.8 ± 0.2 | .02 |
| e’ (cm/s) | 10.4 ± 1.9 | 10.1 ± 2.2 | 10.3 ± 2 | .59 |
| E/e’ | 7.4 ± 1.9 | 7.3 ± 2.2 | 7.4 ± 2 | .81 |
| DEC time (s) | 151 ± 33 | 153 ± 27 | 152 ± 30 | .80 |
| Lat Sm (cm/s) | 11.2 ± 1.5 | 11.5 ± 2 | 11.5 ± 2 | .55 |
| Sep Sm (cm/s) | 9.5 ± 1.8 | 9.9 ± 1.8 | 9.9 ± 1.8 | .45 |
| St (cm/s) | 13.7 ± 2.4 | 13.7 ± 2.0 | 13.7 ± 2.3 | .95 |
| EF (%) | 60.6 ± 3.6 | 60.7 ± 3.1 | 60.7 ± 3.4 | .90 |
| LV3S (%) | −20.6 ± −2.3 | −19.7 ± −1.9 | −20.3 ± −2.2 | .13 |
| LV2S (%) | −21.3 ± −2.7 | −21 ± −2.4 | −21.2 ± −2.2 | .68 |
| LV4S (%) | −21.2 ± −2.2 | −21.2 ± −2.3 | −21.2 ± −2.2 | .93 |
| GLS (%) | −20.8 ± −1.5 | −20.4 ± −1.5 | −20.7 ± −1.5 | .23 |
| GWI (mmHg%) | 2036 ± 149 | 2147 ± 150 | 2075 ± 157 | .001 |
| GCW (mmHg%) | 2374 ± 210 | 2465 ± 204 | 2406 ± 211 | .10 |
| GWW (mmHg%) | 142 ± 64 | 127 ± 42 | 138 ± 58 | .31 |
| GWE (mmHg%) | 94.3 ± 2.5 | 95.1 ± 1.5 | 94.6 ± 2.2 | .18 |
Abbreviations: cm, centimeters; DEC time, deceleration time; EBPRE, exaggerated blood pressure response to exercise; EDD, end diastolic diameter; EF, ejection fraction; ESD, end systolic diameter; GCW, global constructive work; GLS, global longitudinal strain; GWE, global work efficiency; GWI, global work index; GWW, global waste work; IVS, interventricular septum; K, potassium; kg, kilograms; LaD, left atrial diameter; LatSm, Lateral systolic motion; LV3S, left ventricular 3 chamber strain; LV2S, left ventricular 2 chamber strain; LV4S, left ventricular 4 chamber strain; Na, sodium; NBPRE, normal blood pressure response to exercise; PW, posterior wall; Sep Sm, septal systolic motion; St, tricuspid systolic motion.
The parameters associated with myocardial work (MW), including global constrictive work (GCW), global myocardial waste work (GWW), and global myocardial work efficiency (GWE) were not statistically different between the two groups (2374 ± 210, 2465 ± 204, p:.10; 142 ± 64, 127 ± 42, p:.31; 94.3 ± 2.5, 95.1 ± 1.5, p:.18, respectively). In contrast, global myocardial work index (GWI) parameters were different between the two groups (2036 ± 149, 2147 ± 150, p < .001)
In regression analysis, the cofounding variables included age, sex, EF, ESD, EDD, LV mass, IVS, E/e’, E/A, A wave, hemoglobin, creatinine, GWI, GCW, GWW, GWE, and GLS. in univariate regression analysis GWI were statistically different between groups (Table 2).
TABLE 2.
Univariable logistic regression analysis for predicting exercise induced hypertension.
| Variable | Model (crude OR, CI 95%) | p |
|---|---|---|
| Age (38–56) years | 0.72 (0.30‐1.74) | .46 |
| Sex (male reference) | 0.79 (0.21‐2.93) | .72 |
| EF (% 58–% 64) | 1.06 (0.42‐2.65) | .89 |
| ESD (mm) (27–31) | 0.77 (0.43‐1.39) | .39 |
| EDD (mm) (44–50) | 1.10 (0.56‐2.14) | .78 |
| IVS (mm) (9–11) | 0.86 (0.43‐1.70 | .67 |
| LV mass index (68–100) | 1.02 (0.52‐1.99) | .94 |
| E/A wave (from 0.70 to 1.16) | 0.36 (0.15‐0.90) | .03 |
| E/e’ (5.8–8.7) | 0.91 (0.43‐1.90) | .80 |
| Mitral A velocity (0.7–1) (cm/s) | 2.8 (1.14‐6.9) | .02 |
| Hemoglobine (11.8–13.6) (mg/dL) | 01.18 (0.75‐1.85) | .46 |
| Creatinine (0.68–0.93) (mg/dL) | 1.10 (0.58‐2.08) | .76 |
| GWI (1964–2206) (mmHg%) | 3.19 (1.31‐7.77) | .01 |
| GCW (2278–2585) (mmHg%) | 1.93 (0.86‐4.31) | .10 |
| GWE (94–96) (mmHg%) | 1.48 (0.82 – 2.66) | .18 |
| GWW (103–147) (mmHg%) | 0.79 (0.50‐1.24) | .30 |
| GLS (−21.5 to −19.3) (%) | 1.64 (0.73‐3.67) | .22 |
Abbreviations: EDD, end diastolic diameter; ESD, end systolic diameter; IVS, interventricular septum; GCW, global constructive work; GLS, global longitudinal strain; GWE, global work efficiency; GWI, global work index; GWW, global waste work.
Fixed cofounders were determined as E/A, GWE, and GCW for analysis, also GWI and GLS were examined separately with these fixed confounders. The GWI was independently associated with EBPRE (odds ratio with 95% 3.32 (1.02‐11.24), p = .03) (Table 3).
TABLE 3.
Comparation of GLS and GWI models for prediction of hypertensive exercise response.
| MODEL GLS | MODEL GWI | |||
|---|---|---|---|---|
| variable | Odds ratio 95% | p | Odds ratio 95% | p |
| E/A wave (from 0.70 to 1.16) | 0.32 (0.11‐0.95) | .04 | 0.41 (0.15‐1.10) | .08 |
| GWE (from 94 to 96) | 1.55 (0.79‐3.04) | .20 | 1.43 (0.72‐2.86) | .35 |
| GCW (2278 to 2285) | 1.46 (0.60‐3.59) | .40 | 0.19 (0.02‐1.70) | .13 |
| GLS (−21.55 to −19.35) | 2.32 (0.94‐5.78) | .07 | – | – |
| GWI (1964 to 2206) | – | – | 3.34 (1.02‐11.24) | .03 |
Abbreviations: GLS, global longitudinal strain; GCW, global constructive work; GWE, global work efficiency; GWI, global work index; GWW, global waste work.
For examining the discriminative ability of the two models, likelihood ratio chi‐square and R2 analysis were performed. The GWI model showed better values than the GLS model for discriminating the predictable ability for detecting EBPRE. The discriminative index of Harrell's C‐index values in the GWI model was higher than values calculated in the GLS model (c‐statistics measures the discriminative ability of the model, and values closer to 1.0 are better) (Table 4).
TABLE 4.
GLS and GWI model performance comparison.
| Likelihood‐ χ 2 | Adjusted R 2 | C‐index (AUCROC) | |
|---|---|---|---|
| Model‐1 (GLS) | 93.64 | 0.235 | 0.733 |
| Model‐2 (GWI) | 118.56 | 0.283 | 0.769 |
Abbreviations: GLS, global longitudinal strain; GWI, global work index; Harrell's c‐index statistics measures the discriminative ability of the model, and values closer to 1.0 are better; higher values represent better model performance. R 2 higher values represent better model performance.
Correlation analysis showed that E/A values are slightly correlated with GWI and GCW values (Pearson's r −0.296, p:.019; Pearson's r −0.310, p:.014, respectively) shown in Figure 3.
FIGURE 3.
Correlation analysis of GWI and GCW parameters with E/A values.
The partial effect plots were used for GWI to predict EBPRE. According to the results, an increase in GWI predicts the probability of an EBPRE (Figure 4).
FIGURE 4.
Explained outcome variation according to GWI value for predicting exaggerated hypertensive response.
The GWI could distinguish the EBPRE and Non‐EBPRE with an AUC value of 0.703 as the optimal cut‐off point with 77% sensitivity and 68% specificity (Figure 5).
FIGURE 5.
ROC curve analysis for GWI to find optimal cut‐off for exaggerated hypertensive response treadmill exercise.
4. DISCUSSION
According to our results, patients with exaggerated hypertensive response to the treadmill exercise test even without resting hypertension, had higher GWI values than non‐exaggerated hypertensive response patients.
While hypertension is a well‐known clinical risk factor for cardiovascular, and cerebrovascular events and mortality, the prognostic significance of EBPRE is less clear. 11 , 12 It has been suggested that patients with EBPRE with normal resting BPs is predictive of the risk for new‐onset development of hypertension and increased risk for major cardiac events. 12 , 13 , 14 , 15
Marked hypertensive response during exercise is could be seen in normotensive patients and occurs in many patients who diagnosed with hypertension, even when BP is well controlled at rest. 23 Hypertensive response during exercise may be the result of the arterial stiffening that often accompanies diastolic LV dysfunction, EBPRE is also associated with an increased incidence of chronic hypertension development during follow‐up and has been proposed as a preclinical stage of hypertension in some studies. 9 , 10 , 11 However, there are contradictory results in echocardiography studies performed in EBPRE patients, in one study patients who developed EBPRE had worse diastolic functions. 17 On the other hand, Mottram and colleagues showed that patients with EBPRE had similar exercise capacity and left ventricular diastolic function compared with control subjects. 16 Some studies investigated impairment in diastolic function and strain parameters in individuals who developed hypertensive responses to exercise. 18 In our study, we obtained similar diastolic functions between the two groups. Also, patients with EBPRE had similar LV strain analysis results with normal blood pressure response to exercise (NBPRE) patients, and strain parameters were similar between the two groups.
It has been shown that myocardial work analysis can be used in heart failure, hypertrophic cardiomyopathy, ischemic heart diseases, and diabetes mellitus and also gives more sensitive results than echocardiographic strain measurements. 24 , 25 , 26
In studies comparing patients with hypertension and healthy groups, the GWI values were higher in the hypertensive group, but they were not statistically different. 7 On the other hand in another study that compare hypertensive and normotensive patients GWI found higher in hypertensive patients. 27 A study which was done with stress echocardiography showed that MW parameters were similar at rest between HRE and non‐HRE groups, but GWI and GCW values increased significantly in patients who developed a hypertensive response during stress echocardiography, However, the subjects in this study also included patients with a diagnosis of hypertension. 28 In our study, we used stress electrocardiography as a different method to examine and normotensive individuals; it was shown that GWI values in rest were higher and significantly different in normotensive patients, who developed EBPRE during stress electrocardiography.
The underlying mechanism of subtle myocardial dysfunction in EBPRE patients was unclear. In EBPRE patients, BP reaches exaggerated levels at or near peak exercise periods and BP is in the normal range at lower exercise workloads. Arterial stiffness increase during exercise at EBPRE patients causes extra load on the left ventricle, leading to an increase in end diastolic pressure values. LV relaxation slows down and ventricular filling decreases because of increased LV afterload; as a result, the increased left atrial pressure may cause exercise intolerance. 30 Also the adrenergic system and renin‐angiotensin‐aldosterone system, which are frequently activated, may be responsible for this situation. 31 Therefore, we thought it might be related to that, long‐term periodic exposure to exaggerated levels of BP and increased afterload could cause subtle myocardial dysfunction.
It is not possible to evaluate the effect of EBPRE on systolic and diastolic functions in the early period with standard echocardiography. According to our results, EBPRE is associated with subtle effects in myocardial functions determined by myocardial work parameters, even in the absence of resting HT and this may be the earliest abnormality in hypertensive heart disease. we showed that patients with EBPRE also have high GWI values, similar to patients diagnosed with hypertension. 27
While exercise electrocardiography examination performed in daily practice was previously used to diagnose coronary artery disease, its use for functional capacity assessment is prioritized in new publications. 8 When evaluating the test results of patients, conditions such as EBPRE may be ignored because there are no recommendations regarding follow‐up and treatment when EBPRE is diagnosed. However, considering that there could be a process from the diagnosis of EBPRE to the diagnosis of hypertension, patients diagnosed with EBPRE could be diagnosed with hypertension in life long period. As we showed in our study, changes in myocardial work parameters in healthy people who develop EBPRE should be kept in mind in terms of the risk of these patients becoming candidates for hypertension in the future. Therefore, myocardial work analysis in patients diagnosed with EBPRE may be useful in determining who may be more prone to hypertension and these patients could be monitored closely for early diagnosis of hypertension.
4.1. Limitations
The limitations of our study are that the number of patients included in our study was limited, the patients included in the study were considered normotensive based on anamnesis and hospital blood pressure measurements, and the patients did not have ambulatory blood pressure measurements.
5. CONCLUSIONS
Exaggerated hypertensive responders to treadmill exercise test had higher GWI values than normotensive responders. Myocardial work parameter analyses might be used to identify early signs of myocardial involvement in EBPRE patients and these patients could be checked more frequently and early diagnosis of hypertension might be made.
AUTHOR CONTRIBUTIONS
Conception and design: Süleyman Cagan Efe, Ali Karagöz, Nihal Ozdemir. Collection and assembly of data: Süleyman Cagan Efe, Cem Doğan, Zübeyde Bayram, Mahmut Buğrahan Cicek, Ali Furkan Tekatlı, Turgut Karabağ, Murat Karaçam, Baver Bozan, Tuba Unkun. Data analysis and interpretation: Süleyman Cagan Efe, Ali Karagöz, Cihangir Kaymaz, Gülümser Sevgin Halil, Enver Yucel. Manuscript writing: All authors. Final approval of manuscript: All authors.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES
None.
CLINICAL TRIAL REGISTRATION
None.
ACKNOWLEDGEMENTS
We have to express out our appreciations to the MD Ali Karagöz for sharing of his wisdom on statistical analysis with us during the course of this research.
Cagan Efe S, Buğrahan Cicek M, Unkun T, et al. Usability of myocardial work parameters to demonstrate subclinical myocardial involvement in normotensive individuals with exaggerated hypertensive response in treadmill exercise testing. J Clin Hypertens. 2024;26:687–695. 10.1111/jch.14814
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