Lowered Blood Pressure with Exercise

[kd]

I am a 52 yo woman with a 3/4+ MVP/Regurgitation with a hx of stroke and difficult to control isolated systolic high blood pressure. In June, I had a stress echo with the following results: NSPSTChgs, Poor R Wave Prog; EF=60% with mild concentric LVH; NSR with diffuse STT changes; Resting HR=79; Resting BP=164/54; BP at 3 min=148/42; 6min=156/0; 9min=168/0; at 9m52s, HR=126 I started to pass out. There was resting left ventricular hypertrophy and some T-wave inversions and downsloping ST depressions within the exerise portion.  An echocardiogram in Oct. showed grade II dias. dysfunc.; mildly thickened anterior mitral leaflet w/3-4+ very eccentric posteriorly dir MR (cannot exclude a small flail); tri-leaflet aortic valve with mild aortic sclerosis; trivially pulmonic insufficiency. All I can get out of my doc is that the changes can be expected with high blood pressure and someday I'll have to have the surgery for the MR.  However, when he was leaving the room and we were talking about the stress test, I mentioned that usually they have to stop the test because my BP would rise so quickly and that I was proud that I went further in the test and that during the test, my BP actually dropped.  He stopped and said, "Well, that's another issue." and went out the door.
Q1: What are the significance of the stress test wave changes?
Q2: What is the significance of a flail, a concentric LVH, L ventricular hypertrophy?
Q3: Why would a decreasing BP during exercise be important?  What does that signify?
Q4: How many leaflets does an aorta usually have? (not that this is an issue)

[Cleveland Clinic]

kd,

Its really impossible to have a diastolic blood pressure of zero. Perhaps they cant hear it during the test.

The stress t wave changes in the setting of LVH are hard to interpret and annot in themselves constitute an abnormal test.

A flail mitral valve and significant regurgitation should be evaluated further. Better imaging could be seen with a transesophageal echo.  LVH refers to a thickend ventricle. It is usually the result of your ventricle beating against too much bloodpressure. It really emphasizes the need for aggressive blood pressure control.

A decreasing blood pressure in the setting of exercise could signify an abnormal test. You should explore this further with your physician.

The aorta has no leaflets. the aortic valve should have 3.

If you have remaining questions you should really press your doctor for the answers.

[Dr. Erik]

You really had no diastolic BP during the treadmill test? I've never heard of that. You should think of valve repair sooner rather than later. Good luck.

[kd re: longstanding MR]

I've often had the 0 diastolic since the late 1970s; the mvr didn't show up until the mid 1990s.  Typically, nowadays, it is either 0 or there is a double diastolic at 40 and then again at 0.
The only explanation I have heard is my premature atherosclerosis - but there was no evidence of that until the 90s, either.  So...? Beats me.

[raildown]

what is 'double diastolic' ??

[kd re: longstanding MR]

From what I understand, when you listen to your blood pressure, the number at which you first hear your heart sounds is the systolic.  As you listen longer, there will be a large drop/change in the intensity of your heart sounds and this represents the diastolic.  Usually, the sounds fade out at that point.  In my case, I hit a diastolic between 40 and 50 (closer this year to 40) and then it remains loud until lower and many times to 0.  My hypertension doctor has me record both as a higher and lower (double) diastolic.

Occasionally, I will have a higher systolic and a seeming diastolic and then it will get a lot louder for what might appear to be another systolic followed by another diastolic.  It is weird and I have no idea of what THAT is.  I choose to ignore it.

[raildown]

w.r.t. the idea of "double diastolic (ad somettimes systolic):

think you should _serioulsy_ consider changing your
" hyperstension doctor";

//

[kd re: longstanding MR]

I know that technically you are right about not having a diastolic.  I was told by a CCF neurologist when I did a short "stairstep" exercise and I had a BP of 300+/0 that I may have a blood pressure that is not measureable by conventional means.  However, since all I have is conventional means, my doctors (including some at CCF) cite a diastolic of 0 when it is palpable or very audible at the end of the measuring range.  Sometimes the nurse has been able to hear my heart beating before the stethescope gets to my arm.  It pounds pretty hard sometimes.

Thanks for all your information.  I probably should make the trip up to CCF but it is so far and I don't have an easy means of transportation.  All the cardios around here are interconnected and some docs take offense at seeking information from someone else (especially in their group) but I will think about it really hard.

It's too bad noone told me that the hypertension would hurt the heart.  I knew it could create more plaque with an increased risk for stroke but no one said anything about actually causing heart damage.  I might have put up with more syncope, etc. in order to keep it down.

Thanks again,
kd

[kd re: longstanding MR]

Thanks for your concern.  However, my hypertension doc really is good.  There are several doctors who measure it this way so it is not just her.  If you heard my blood pressure you would understand why it is documented this way.  It is pretty weird.

[raildown]

what is a "hypertension doc" ? a family doctor ?an internist
??

what is "hx of stroke" ?? have you had a stroke ?IIRC dx means diagnosis ;

docs who frown on second  opinions are not great docs....;

are you taking medications ?

be well;

[kd re: longstanding MR]

Hey there!  Thanks for the concern...I am trying to "be well."  As to strokes - I have had 8 since 1995 and a multitude of transischemic attacks (TIAs).  All except this last one were thinking and memory strokes. They are all backed through MRIs, CTs and SPECT tests. This last one was mostly strength as it hit the brainstem.  I have also had clots in my peripheral artery system (arm and leg).  There is no known reason for them.  I have been tested every which way.  We suspect it is an unnamed autoimmune disorder on the order of antiphospholipid antibody syndrome.  
A hypertension specialist is a nephrologist (kidney doctor).  Since many causes of hypertension revolve around the kidneys (altho mine do not), nephrologists have a good handle on the meds and control of hypertension.

[cutestuff2]

A hypertension dr. is one who specializes in the treatment of blood pressure.  A family dr., internist can prescribe meds and order testing, but a hypertension dr. (at least the one my parents goes to) specializes in nephrology or kidney disorders.  Many times hypertension can be a sign of kidney trouble, or eventually lead to kidney trouble.