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There is considerable evidence to support the beneficial effects of exercise on cardiovascular health. However, it remains controversial whether physical exertion in the workplace provides the same benefit as sports physical activity (PA). In a study of 3576 employed men with no cardiovascular disease (CVD) at baseline, low levels of occupational PA were associated with a higher risk of CVD events over a median follow-up of 14 years compared with those with moderate occupational PA (1.66, 95% CI 1.06 to 2.59) but higher levels of occupational PA were not associated with a reduced risk of CVD.1 Congruent with previous studies, sports PA was associated with reduced CVD event rates but the protective effect of sports PA was only seen in sedentary workers. Paradoxically, men with high levels of occupational PA who also engaged in recommended levels of sports PA paradoxically had higher CVD event rates (table 1).2
In the accompanying editorial, Coenen1 suggests several possible explanations for this apparent paradox including differences in the duration or intensity of occupational versus sports PA, inadequate recovery times after activity, confounding lifestyle factors or methodological limitations in self-reporting of activity compared with accelerometer data. Even so, he concludes: ‘The benefits of being physical active are apparent and undeniable in primary and secondary (cardiovascular) disease prevention. However, it appears important that clinicians (including cardiologists) and other healthcare practitioners (eg, general practitioners, occupational physicians and physical therapists) distinguish leisure time from occupational physical activity. Moreover, among these practitioners, a particular focus on vulnerable groups (with lower fitness and underlying diseases and from lower socioeconomic position) is needed. An important implication is that practitioners should be aware of the occupational demands of their patients and incorporate this in their messages towards preventing disease by integrating physical activity in clinical practice.’
Treatment of hypertension is an essential element of primary prevention of CVD. Yet, the validity of using blood pressure (BP) measurements in the office at a single point in time to determine the need for and efficacy of hypertension therapy is questionable. In order to estimate the prevalence of ‘white coat’ hypertension, BP was measured in 1000 subjects after 5 min of rest, with repeat measurement every 2 min for a total of four measurements.3 When the initial BP was compared with the mean of the subsequent three measurements, 34.3% of the patients initially diagnosed as hypertensive were reclassified as normotensive—so-called ‘white coat’ hypertension. Conversely, 3.4% of normotensive patients were reclassified as hypertensive (eg, ‘masked’ hypertension), with hypertension defined as a systolic BP ≥140 or a diastolic BP ≥90 mm Hg (figure 1).
Although Lavie and co-authors4 agree with the authors that using a single BP measurement is suboptimal, they suggest we need to go even further in our efforts to improve accuracy of hypertension diagnosis. ‘Although multiple office BP measurements may be preferred to single office measurements as demonstrated by Burkard et al,3 clearly BP measurements outside of the office are needed to assess masked HTN, white coat HTN, as well as improve patient engagement and lifestyle interventions. The increased use of technology continues to advance the treatment of many chronic diseases, and certainly digital tools are needed to improve both patient engagement and BP control in the modern era’ (figure 2).
Women with hypertensive disorders of pregnancy are at increased long-term risk of CVD. However, short-term CVD risk after a pregnancy complicated by a hypertensive disorder has not been well studied. Based on administrative hospital discharge data from Florida, Jarvie and colleagues5 examined the risk of readmission for CVD disease within 3 years for almost 1.5 million delivering mothers of single infants. The CVD readmission rates were higher in women with a hypertensive disorder of pregnancy (6.4 vs 2.5/1000 deliveries; p<0.001): a difference that persisted on multivariate analysis (OR 2.41; 95% CI 2.08 to 2.80). In addition, African-American women had higher rates of CVD readmission compared with whites, even after adjustment for hypertensive disorders of pregnancy (OR 3.60; 95% CI 3.32 to 3.90) (figure 3). These data emphasise the need for appropriate primary prevention of CVD and close follow-up in women who experience a hypertensive disorder of pregnancy.
The Image Challenge in this issue shows dramatic ECG changes in an athlete and discusses how to interpret this finding. Be sure to encourage your cardiology trainees to submit Image Challenge questions. No doubt you all see interesting images in your clinical practice every day—share them with others in this educational format!7
Competing interests None declared.
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Provenance and peer review Commissioned; internally peer reviewed.
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