Exaggerated exercise systolic blood pressure response and risk of stroke in patients with known or suspected coronary artery disease

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Purpose: There is some evidence to suggest that an exaggerated exercise systolic blood pressure response (EESBPR) may be associated with future risk of stroke in healthy middle-aged men. However, the value of an EESBPR for predicting stroke in patients with known or suspected coronary artery disease (CAD) referred for stress testing has not been investigated. Methods: Exercise echocardiography was performed in a community-based sample of 6669 patients with known or suspected CAD between March 1995 and December 2007. Patients who had received betablockers within 48 hours before testing were excluded. An EESBPR was defined as a peak exercise systolic blood pressure >220 mmHg. The ratio between the increase in systolic blood pressure and the duration of exercise (RISBPDE) was also estimated. The primary end-point was stroke of any type. Secondary end-points were ischemic stroke and hemorrhagic stroke. Results: Mean age was 62±12 years, and 4151 patients (62.2%) were male. A total of 318 patients exhibited an EESBPR during the tests. During a mean follow-up of 6.9±4.2 years there were 248 strokes of any type, of which 195 were ischemic and 55 hemorrhagic. Ten-year rates of stroke of any type, ischemic stroke and hemorrhagic stroke were 6.7%, 5.6%, and 1.6% in patients with EESBPR vs. 5.5%, 4.2% and 1.3% in those without EESBPR, respectively (p >0.5 for all comparisons). Similarly, there was no significant univariate association between RISBPDE and the occurrence of any stroke (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.97-1.04), ischemic stroke (HR 1.00, 95% CI 0.96-1.04) or hemorrhagic stroke (HR 1.02, 95% CI 0.95-1.10). In Cox regression analysis, a history of hypertension at rest (HR 1.58, 95% CI 1.21-2.05, p = 0.001), male sex (HR 1.42, 95% CI 1.09-1.85), age (1.04, 95% CI 1.03-1.06) and diabetes mellitus (HR 1.38, 95% CI 1.02-1.86), remained predictors of the primary end-point. EESBPR was not a predictor of any of the endpoints evaluated. Conclusions: In our series of patients with known or suspected CAD referred for exercise echocardiography, an EESBPR did not add significant prognostic information for the prediction of stroke over that provided by traditional cardiovascular risk factors.

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