Exercise induced hypertension and atheroschlerosis

[runnertom]

I have posted on this forum in the past in regard to my "unexplained" LAD blockage and subsequent CABG. At age 54 after 30 years of very active running and cycling, I was diagnosed with a blockage of the LAD at the bifurcation. The only symptoms I was having was shortness of breath in the first 1/4 mile or so of my daily runs.Presumably, this was due to my fairly extensive collateral network.  My risk profile appeared to be benign with LDL of 130, HDL 60, never smoked, not diabetic, and normal ambient blood pressure. Family history was not perfect as father had CABG at age 68 after lifetime of smoking. Mother well at 82. I did find post surgery that my homocysteine was high. In a stress test some months prior to the blockage diagnosis it was reported that the test was terminated due to exaggerated blood pressure response to exercise. I was never told of this. Peak systolic pressure reached 230mm at about 15 METs. More recently, I was found to have LVH with septal wall of 15mm. It reversed to 11mm after 8 months of 5mg of lisinopril.
I have now run into an an article documenting severe atheroscherosis and calification in a 30 year marathon runner with exercise induced hypertension with an otherwise "clean" risk profile (Am J Cardiol 2007;99:743-744). Is it possible that this exercise induced hypertension is what is behind my otherwise unexplained disease? Do I need to quit running? With statin therapy, my LDL is now 88 and I am on a low dose of Toprol XL for occational Afib.

[Forum-M.D.-bkj]

tom,

thanks for the post.

What you are looking at is a single case report. I would have a hard time attributing the atherosclerosis to the exercise.  We just do not see exercise leading to the development of heart disease. I would think that that person had a genetic disposition or some other unexplained risk for the CAD.

I can't recommend a specific training regimen since I do not know you, but I would continue with what your previous physicians have recommended and not put too much credence in that single case.

good luck

[e.r.boy]

It just goes to show that the medical industry needs to get ff the magic bullet syndrome of trying to deal with diseases. My brother was a runner, swimmer, biker. No other risk factors other than some family history ( men dying in 70's). He died at 47 of severe muti focal CAD with 100% stenosis in two coronary arteries and 50-75% in two others. An ECG just prior to his death was normal. The latest medical bandwagon is LDL concerns. There are many examples of people with excellent lipid levels who like my brother are still getting ill. Even excellent lipids is no guarantee you're out of the woods.

[EchoTech]

I would say if anything, the exercise is helping you keep the blood pressure down.  No one can refute how exercise does the body good with few exceptions.   I would put forth the idea that the CAD and high exercise induced BP just happened to be found together, but that they don't "feed" off each other so to speak.  The blood pressure medicine is working as the regression of your LVH back under normal limits demonstrates.  Severe CAD and bypass at age 54 is not that uncommon.  You didn't seem to exhibit any of the classic symptoms, and actually the exercising  may have helped bring your heart in to tip top condition, which in all likelyhood helped you to survive and recover.  There may never be a satisfactory answer to why you have disease, just that you must deal with it.  I would encourage you to keep running.

Good night and good luck.

[kitcurious]

Every reasonable person already knows there are no magic bullets for anything. There are probabilities and overwhelming likelihoods.  Wisdom suggests that playing against what you know is the best thing for your health  will shorten the span of time you were given. People are not born with equal propensities. Leading a healthy lifestyle will improve the condition of the individual, not make us all live to be 100.

[runnertom]

I appreciate the comments and the fact that my hypothesis and the one presented in the article is not exactly mainstream. Everyone knows that exercise is good for you. However, in the subset of people with exercise induced hypertension that insist on working out at high intensity, there may be some risk. I met with my cardiologist this morning and we agreed that it would be prudent to titrate my current dose of beta blocker upwards to my tolerance limit. There was a further publication that documents the effeciveness of beta blockers on reducing exercise induced hypertension and also warns that those in my category really should consider beta blocker therapy. (J Am Coll Cardiol, 2006 Vol 47, 794-798)

[tickertock]

I personally think that you are correct in pursuing all possible avenues, including as to why this happens in a subset of persons and that you are doing the right things that will have a positive effect on your overall outcome & health in years to come.It is great that you have found a cardiologist that is willing to help you out with your own conclusions through your own research( this is not the path for everyone) as it can be detrimental also, but from my own experience if I had not did my research regarding my various ailments i would have still be left hanging without a diagnosis to this day & would still be passed off as a "neurotic" of which I'm willing to admit that a little neurosis will always be a part of who I am, but also a part of which I'm not willing let get the upper hand of me anymore. Good luck & keep us updated.

[EchoTech]

If you are that interested to see if your hypertension is still present with exercise, try to talk your doctor into giving you a stress test or just running you on the treadmill and taking your BPs.  An alternative is get a helper who knows how to take BPs, get on a treadmill and have the helper take your BP thru the workout at a fitness club or  a treadmill at home.  That would answer your question.

[runnertom]

I'm going on the treadmill tomorrow morning. Hopefully, I will come away with a relationship between heartrate and blood pressure. I guess the only issue would be what blood pressure would be appropriate as a "redline". I think this is uncharted territory.

[EchoTech]

Just so you know, the blood pressure usually goes up when people exercise.  As to what the normal limits are for people while execising, I really don't know.  I know we don't like to see 200+, but honestly I can't give you any good guidelines and tell you what is normal/abnormal.  

[save]

I am in cardo rehab, and I am being told that my blood pressure goes too high during exercise.  Also, I have to stay until I can get my heart rate down.  I finally got it down to 90 and they let me leave.  I had open heart surgery, but they did not do the LAD, plus 4 other  arteries.  They are concerned now because I am having symptoms.  I am repeating myself to you because I know you get lots of questions.  I also had the valve done as well as arteries.  I am now getting jaw and chest discomfort.  They want me to have another cath which I am avoiding at this time.  Lately I have had symptoms at rest and have them after exercise.  Why is the blood pressure and heart rate a concern to them.  I had been exercising a lot before surgery.  It feels like a snails pace at rehab, but I do get some symptoms - not bad.  I think if  I can get into more exercise that I maybe able to control some of the symptoms.  Am I wrong about this idea?  I am on the patch again, Toprol XL and they make me take a nitro pill before I exercise with them.  I have been told by some people that they had symptoms after surgery.  It is confusing.

[EchoTech]

You have a very complicated case, and I really don't have a good straight answer for you.  I also lack the knowledge to put into the context of your overall health.  I can explain that when your blood pressure gets reallly high (200+) you can create generate enough pressure in  the ventricle and inside the heart muscle that you can't proprerly perfuse the heart muscle  because the coronary arteries rely on diastolic pressure to force blood through the coronaries.  In other words the pressure inside the coronary arteries will be greater than the pressure in the aorta, so you won't be able to get oxygenated blood into the coronaries, which most likely leads you to have symptoms.  The reason they want to see the heart rate down could be many, but in general, if the heart rate is over 100, generally speaking, that means that there is something irritating the heart in adults.   There are a lot of other reason why too, but again, I don't have enough knowledge to give you a good answer.  If you are becoming more and more symptomatic, that means they will press you harder to have the cath.   If I were in your shoes, I would submit to having the cath.  They don't recommend doing caths just for the heck of it, you know and they know that it is possible to have a serious complication for a cath, including stroke and death.  They wouldn't be recommending it if the benefits didn't outweigh the risks.  You are the ultimate boss in the whole situation, and I hope that pick the best option for you.  I wish I could help you more, but I am very limited in what I know.

Good night and good luck, Tom.

[save]

Thank you for all the information you give to me.  It really does help.  I know that I must make up my mind to the cath.  You are correct that they would not suggest it if they did not think that they needed to take a look.  He told me that symptoms with blockage is not good.   I am the one running from the situation.  I was told at rehab on Friday that I have to see the cardologist before I can come back.  While exercising,   I got very high blood pressure, lost oxygen numbers, and got nausea at the end of the treadmill.  The nurse gave me oxygen.  She said that I had gotten pale.  I also took more nitro which helped.  The oxygen and the nitro seemed to do the trick for me.  Thanks again.

[runnertom]

Well, I had the treadmill and I was somewhat disappointed in the results. I had taken 25mg of metroprolol prior to the test but still hit a bp of 220 at a pulserate of 170 during stage 5. I stopped at that point as the 220 was higher than I wanted to see. I did find in the next few minutes that the bp stayed up long enough for me to measure it myself with my home unit at the end of a run. The next day, I recorded a bp of 213/100 at the end of a hard run, still on the 25mg. The next day, I doubled the metroprolol and recorded a 193/89. I think I can live with this (no pun intended). My resting pulse is a bit low at 40 but thats only about 5 to 7 lower than normal and I really don't have any other symptoms. If anything, the running itself feels pretty good, not what I expected on that dose of a beta blocker. Maybe its due to the diastolic filling thing you were referring to.

[freesiagirl]

Hi!  I was wondering if I could get some advice.  I have had heart palps for years now, then worsening shortening of breath on exertion over the course of a few years, and then 6 months ago, started having chest pain on even slight exertion.  My doc sent me for tests, ekg, chest xray, and holter monitor for 24 hours.  In the meantime, I had to make a trip to the ER  and was then sent for a treadmill stress test.  At night, my heart rate drops down to the mid-40's.

I am a 34 year old female with low blood pressure and no family history of heart disease.  I don't smoke.  During the stress test, my blood pressure went to 309/43, yes, three hundred nine at 9 minutes.  The nurse asked if I was ok, and I shook my head no, as at this point, I was gasping for air, and couldn't speak.  Also, my head was killing me.  The nurse didn't stop the treadmill immediately.  I should add that before the test started, she told me that she was new and was worried that she might mess something up, and during the test, as my blood pressure was going up and up and up, she was acting extremely nervous, like she didn't know what to do.  When I sat down, I kept asking for a drink of water or a wet paper towel to put on my face, because I thought I was going to throw up or pass out.  Also the spect imaging part of the test afterwards was abnormal.  

The next time that I went to the ER with chest pain, I was admitted, and had a cath.  The cath was ok, with mild atherosclerosis.  My concern is that I have done research on the WISE study, which shows that in women, heart disease isn't always apparent on Cath, because in women it isn't always a blockage as is the case in men, but an even narrowing of the arteries, which doesn't show up on cath.    My cardiologist has completely dismissed me because of the clear cath.   He actually had the nerve to tell me that I had a large chest and that was causing my chest pain.  ARGH!  That wouldn't cause shortness of breath, and extremely high blood pressure on exertion.  
If anyone has any suggestions, I would greatly appreciate it.  THANks so much

[EchoTech]

I believe you might be confusing fitness with being healthy.  It is awesome that you are 54 and can do stage 5 of the Bruce protocol, it is a very uncommon thing.  I must admit I am really concerned with the statement that you can "live with it" with your BP being in the 190s when you exercise.  your body can tolerate hypertension for a long time, even when it is destroying your body.  They call it the silent killer because when it is doing the damage, it doesn't hurt while it's happening.  It can really ruin your quality of life while you still have many years left to live.

What is your resting BP?

Good night and good luck.

[EchoTech]

Given your lack of risk factors, and that you are pretty young, the probability that you have microvascular disease in the endocardium is very low.  I had to read up on the WISE study, and I'll say a few things, which are my opinion, and remember, I'm not a doctor.  The first is that it is a relatively small study from what little I have read.  It points possibilites in some directions, but there are no real answers on how to reliably assess for microvascular abnormalities at this point as far as I can discern. Secondly, the cardiologist that does caths on a regular basis isn't going to be fooled by an even application of plaque on the vessel wall vs. the big lumpy blockages that are more typically seen.  It would be possible, but highly unlikely.  If you that bound and determined, you could get a copy of the cath films and visit another cardiologist to get a second opinion, perhaps one that specializes in women's health.  If your symptoms are worsening and you feel you are not getting the right attention, then it is your duty to take care of yourself and get a second opinion.

  As far as the high blood pressure when you had your treadmill stress test, I don't think the readings you got are physically possible and were recorded in error.  I'm not saying that you didn't have high blood pressure, but there are two things that make this implausable 1. if your systolic went to 309, you wouldn't physcially be able to perfuse your heart muscle since they would be clamped down inside the heart muscle itself from that pressure. 2. there isn't enough time between cardiac cycles for the blood pressure to swing 240 + points.   100 or so maybe, but not that much. This doesn't minimize your current symptoms, it just  allows to put the test in the right perspective.

Good night and good luck.

[runnertom]

Echo,
   My comment that "I can live with 190 systolic" meant that it would appear to be out of the danger zone during exercise-especially when the 170 heartrate at that point is not hit too often in my normal workouts. The other side of this is that my normal resting pulse of mid 40's is still above 40 even on the 100mg/day metroprolol and I am not having any obvious symptoms associated with it. My resting bp runs around 100 to 110 over 60 to 70.
   Some additional info has come to light. I had a cardiac CT a few weeks ago and the report said my LIMA graft is now occluded-quite unusual as you know. Cardio went back to the original cath and found that the LAD blockage was not all that bad.  This is likely causing the graft to have reduced flow and ultimate occlusion (string phenomena). The good news is that the LAD blockage must not have progressed much in 4 years since I am not symptomatic and showed no EKG changes during the treadmill. The venous graft to the first diagonal that was quite "tight" is not showing signs of occusion. Hopefully, the fairly agressive lipid management is responsible since I have changed very little else since my surgery.

[EchoTech]

That's good, I thought that you might have had resting hypertension despite medical therapy.  Good luck to you.