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SYSTOLIC BLOOD PRESSURE IN REPEATED EXERCISE TESTS AFTER MYOCARDIAL INFARCTION Kamile L Blozneliene, Laima Talijuniene Kaunas Medical University Institute of Cardiology Key words: acute myocardial infarction, systolic blood pressure, exercise tests, prognosis after acute myocardial infarction. Summary. Exercise testing still remains the cornestone of non-invasive eveluation of functional statement in patients after acute myocardial infarction (AMI). The purpose of the present study was: to analyse the relationship between hypertension at the early exercise testing (ET) and development of fatal coronary events in patients with AMI; to assess the changes in systolic blood preasure (SBP) parameters obtained by repeated exercise testings ant to define their informativeness in terms or poor outcome after myocardial infarction (MI). Design and methods 468 consecutive patients have undergone ET within 3 weeks of AMI. The Kaunas Acute Myocardial Infarction Register data were used for survival analysis. During 48-120 months follow up period there were 98 cardiac lethal outcome and 370 survivors. Among non-survivors within 48-120 months after AMI there were only 8 patients (8.2%) who had hypertensive (=>220/115 mmHg) response to exercise. In 253 patients exercise tolerance was assessed by ET 3,12 months and 2, 3 and 5 years after AMI. Within the first 2 years after MI there were 20 cases of cardiac deaths, 23 cases of recurrent MI, 56 cases of left ventricular failure (HF) NYHA class II-IV. Results. The cardiovascular responce to ET within 3 weeks after AMI was following: the mean peak workload 44.0+-0.7 W, the mean peak heart rate 110.0+-0.5 bpm/min, the mean peak SBP 157.4+-0.9 mmHg. Cardiovascular response to ET 3 months after MI: mean peak work load 48.62+-0.90 W; mean peak heart rate 128.48+-1.3 bpm/ min;mean peak SBP 177.78+-1.33 mmHg; mean systolic blood pressure increment (SBPI) 41.72+-1.25%. Eleven patients died suddenly within 6 months after AMI, however this group had no patients with hypertensive response to exercise at the early exercise test (3 weeks after AMI). There was no correlation between SBPI 3 months after MI and rate of cardiac deaths, cases of recurrent MI within the first 2 years after MI. Nevertheless in the survivor persons suffering from HF at 2 years after MI, SBPI was found decreased at 3 months after MI already compared with patients without HF: 35.6-1-4.8% and 38.0-1-1.6% respectively. Difference between SBPI at 1 year after MI and SBPI at 3 months after MI were -1.3+-5.8% and 2.63+4.8% respectively (p<0.005). In patients suffering from HF at 5 years after MI, ET repeated 3 years after MI showed statistically significant smaller increase of SBPI parameter values compared with SBPI in the patients without HF 5 years after MI: 30.8-1-5.2% and 37.8+-2.1% respectively (p<0.01). Conclusion: SBP increment parameters in repeated exercise tests may help detect persons prone to develop heart failure after AMI. Exercise hypertension within 3 weeks after myocardial infarction had no influence on long-term survivor after AMI. Seminars in Cardiology. 2001;7(2):57-59 Sistolinis kraujospudis kartojant fizinio kruvio meginj sergantiesiems miokardo infarktu. Raktazodziai: uminis miokardo infarktas, sistolinis kraujospudis, fizinio kruvio meginys, prognoze po uminio miokardo infarkto. Reziume. Darbo tikslas: tirti priklausomybeę tarp hipertenzines reakcijos j fizinj kruvj atliekant ankstyvajj fizinio kruvio meginj (FKM) ir sveikstanciuji} po miokardo infarkto (MI) koronariniij mirciij; jvertinti sistolinio kraujospudzio prieaugio, kartojant fizinio kruvio meginius po MI, prognostinj informatyvumą. 468-iems sveikstantiesiems po uminio MI trečią susirgimo savaitę atliktas fizinio kruvio meginys (FKM). Jij isgyvenamumas nustatytas remiantis Kauno miesto Uminio Miokardo Infarkto Registro duomenimis. Stebejimo trukme 48-120 men. Isgyveno 370 asmenij. 98 asmenys mire koronarine mirtimi. Mirusiujij per 48-120 men. po MI grupeje tik 8 (8.2 proc.) pacientams ankstyvojo FKM metu buvo nustatyta hipertenzine reakcija j fizinj kruvj (=>220/115 mmHg). Vienuolika asmenij mire staiga per pirmajj pusmetj po MI, taciau sioje grupeje ne vienam pacientui ankstyvasis FKM nesukele hipertenzines reakcijos j kruvj. 253 pacientams FKM buvo atliktas po 3,12 menesiij ir po 2, 3, 5 metij po MI. Mazas sistolinio kraujospudzio prieaugis kartotinai atliekant FKM statistiskai patikimai (p<0.01) siejosi su kairiojo skilvelio nepakankumumu, praejus 5 metams po MI. Isvada. Tyrinejimi} rezultatai rodo, kad sveikstanciujij po miokardo infarkto hipertenzine reakcija j fizinj kruvj neturi rysio su atokiuoju isgyvenamumu; mazas sistolinio kraujospudzio prieaugis kartotinai atliekant FKM statistiskai patikimai siejasi su kairiojo skilvelio nepakankumumu, praejus 5 metams po MI. Kardiologyos seminarai. 2001;7(2):57-59 Introduction. Exercise testing still remains the cor-nestone of non-invasive evaluation of functional statement in cardiac patients and is almoust uniformly performed after acute myocardial infarction [1]. Inadequate blood pressure response to exercise testing (ET) at the early exercise test in acute myocardial infarction (AMI) patients is thout to be associated with the occurrence of fatal coronary events [2-5].The purpose of the present study was: to analyse the relationship between hypertension at the early ET and development of fatal coronary events in patients with AMI; to assess the changes in systolic blood preasure (SBP) parameters obtained by repeated exercise testings and to define their in-formativeness in terms of poor outcome after myocardial infarction (MI). Patients and methods. Patients convalescing from AMI were eligible for this study within the first three weeks after AMI. At the time of testing, none of patients had contraindications for ET, such as unstable angina, severe heart failure, seriuos venricular arrhythmias, heart block or significant hypertension (> 160/100 mmHg); thoug, in some cases seriuos complications had occured during the acute phase of myocardial infarction. A symptom-limited exercise test was performed on the cycle ergometer (Elema-Schonander EM 370/796) with a starting load of 25 W and with 25 W increments every 5 minutes. Exercise ECGs were registered on the electrocardiograph (Elkar 7623) with an on-line ECG (leads I, II, aVF, V2,4,6) or on the Mingograph 740 (Si-emens-Elema). From the Mingograph, on-line paper prints out of six chest leads were produced at 10 mm/s paper speed continuously and a 12 lead ACG at 50 mm/ s paper speed was registered every minute.Significant ischaemia was defined as ST-segment depression of at least 1mm, horizontal or downsloping, 80 ms from the J-point. Cuff blood pressure was measured at 1-minute intervals during the exercise and during recovery period of 10 minutes. We stopped the exercise when the patient reaches 75% of maximal heart rate or the patient is unable to continue because of chest pain, general and/or leg muscle fatigue (or) dyspnoea. For safety we also stopped the exercise if there was a fall in systolic blood pressure or hypertensive response to exercise (=>220/ 115 mmHg) or the following parameters were registered: ST-segment depression = >2 mm, ST- segment elevation = > 1 mm (in leads without diagnostic Q-waves) or a severe ventricular arrhythmias. 468 consecutive patients have undergone ET within 3 weeks of AMI. The Kaunas Acute Myocardial Infarction Register data were used for survival analysis. During 48-120 months follow up period there were 98 cardiac lethal outcome (Fig.l) and 370 survivors. Among non-survivors within 48-120 months after AMI there were only 8 patients (8.2%) who had hypertensive (=>220/ 115 mmHg) response to exercise (Fig2). In 253 patients exercise tolerance was assessed by ET 3,12 months and 2, 3 and 5 years after AMI. Within the first 2 years after MI there were 20 cases of cardiac deaths, 23 cases of recurrent MI, 56 cases of left ventricular failure (HF) NYHA class II-IV. Results and discussion. Results. The cardiovascular responce to ET within 3 weeks after AMI was following: the mean peak workload 44.0+-0.7 W, the mean peak heart rate 110.0+-0.5 bpm/min, the mean peak SBP 157.4+-0.9 mmHg. Cardiovascular response to ET 3 months after MI: mean peak work load 48.62+-0.90 W; mean peak heart rate 128.48+-1.3 bpm/min;mean peak SBP 177.78+-1.33 mmHg; mean systolic blood pressure increment (SBPI) 41.72+4.25%. Eleven patients died suddenly within 6 months after AMI, however this group had no patients with hypertensive response to exercise at the early exercise test (3 weeks after AMI). There was no correlation between SBPI 3 months after MI and rate of cardiac deaths, cases of recurrent MI within the first 2 years after MI. Nevertheless in the survivor persons suffering from HF at 2 years after MI, SBPI was found decreased at 3 months after MI already compared with patients without HF: 35.6+-4.8% and 38.0+-1.6% respectively. Difference between SBPI at 1 year after MI and SBPI at 3 months after MI were -1.3+-5.8% and 2.63+-1.8% respectively (p<0.005). In patients suffering from HF at 5 years after MI, ET repeated 3 years after MI showed statistically significant smaller increase of SBPI parameter values compared with SBPI in the patients without HF 5 years after MI: 30.8+-5.2% and 37.8+-2.1% respectively (p<0.01). Physical activity as an indispensable condition for the proper functioning of the human organism is important for understanding cardiovascular diseases and especially for prescribing appropiate therapies [6-7]. The exercise electrocardiography still remains the first importance of risk stratification after AMI.Exercise capacy and heart rate and blood pressure reaction relate to myocardial ischaemia, left ventricular function and the peripheral haemodynamic response to exercise. Therefore, in order to predict the patient's outcome more effectively one should use combinations of these parameters [6-8]. As it is shown by our study the exercise hypertension within 3 weeks the systolic blood pressure increment in repeated exercise tests after AMI had no influence to long-term survival. Nevertheless the systolic blood pressure increment parameters in repeated tests may help detect persons prone to develop heart failure after myocardial infarction. References 1. Bigi R, Galanti A, Curti G, et al. Prognostic value of residual ischaemia by exercise electrocardiography in low-risk patients following acute myocardial infarction. Europen Heart Juornal 1997;18:1873-1881. 2. Fioretti P, Brower RW, Simoons ML, et al. Relative value of clinical variables, bicycle ergometry, rest radionuclide ven-triculography and 24 hour ambulatory electrocardiographic monitoring at discharge to predict 1 year survival after myocardial infarction. J Am Coll Cardiol 1986;8:40-49. 3. Nielsen JR, Mickley H, Damsgaard EM, Froland A. Predis charge maximal exercise test indentifies risk for cardiac death in patients with acute myocardial infarction. Am J Cardiol 1990;65:49-153. 4. Arnold AE, Simoons ML, Detry JM, et al. Prediction of mortality following hospital discharge after thrombolysis for acute myocardial infarction: is the a need for coronary angiograp-hy? Eur Heart J 1993;14:306-315. 5. Villella A, Maggioni AP, Villelle M, et al. Prognostic signifi-cate of maximal exercise testing after myocardial infarction treated with thrombolytic agents: the GISSI-2 data-base. Gruppo Italiano per lo Studio della Soprawivenza Nell'In-farto. Lancet 1995;346:523-529. 6. Lewis WR, Amsterdam EA. Utility and safety of immediate exercise testing of low-risk patients admitted to the hospital for suspected acute myocardial infarction. Am J Cardiol 1994;74:987-990. 7. Hamm LF, Stull SA, Crow RS. Exercise testing early after myocardial infarction: historic perspective and current uses. Progr Cardiovasc Dis 1986;28:463-476. 8. Forslund L, Hjemdahl P, Held C, et al. Prognostic implications of results from exercise testing in patients with chronic stable angina pectoris with metoprolol or verapamil. Eur Heart J 2000;21:90l-9lO.