Usefulness of cardiopulmonary exercise testing to predict the development of arterial hypertension in adult patients with repaired isolated coarctation of the aorta

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Abstract

Background

Patients who underwent surgery for aortic coarctation (COA) have an increased risk of arterial hypertension. We aimed at evaluating (1) differences between hypertensive and non-hypertensive patients and (2) the value of cardiopulmonary exercise testing (CPET) to predict the development or progression of hypertension.

Methods

Between 1999 and 2010, CPET was performed in 223 COA-patients of whom 122 had resting blood pressures of < 140/90 mm Hg without medication, and 101 were considered hypertensive. Comparative statistics were performed. Cox regression analysis was used to assess the relation between demographic, clinical and exercise variables and the development/progression of hypertension.

Results

At baseline, hypertensive patients were older (p = 0.007), were more often male (p = 0.004) and had repair at later age (p = 0.008) when compared to normotensive patients. After 3.6 ± 1.2 years, 29/120 (25%) normotensive patients developed hypertension. In normotensives, VE/VCO2-slope (p = 0.0016) and peak systolic blood pressure (SBP; p = 0.049) were significantly related to the development of hypertension during follow-up. Cut-off points related to higher risk for hypertension, based on best sensitivity and specificity, were defined as VE/VCO2-slope  27 and peak SBP  220 mm Hg. In the hypertensive group, antihypertensive medication was started/extended in 48/101 (48%) patients. Only age was associated with the need to start/extend antihypertensive therapy in this group (p = 0.042).

Conclusions

Higher VE/VCO2-slope and higher peak SBP are risk factors for the development of hypertension in adults with COA. Cardiopulmonary exercise testing may guide clinical decision making regarding close blood pressure control and preventive lifestyle recommendations.

Introduction

Adults after surgery for aortic coarctation (COA) require lifelong follow-up because of increased late cardiovascular morbidity and mortality [1]. This is mainly due to the development of arterial hypertension and the occurrence of vascular complications [2], [3], [4], [5]. It is estimated that up to 75% of patients with repaired COA develop hypertension within 20–30 years after surgery [2], [6]. Repair with prosthetic material, late repair, male gender and older age were the most important predictors of late systemic hypertension [6].

In adult patients with congenital heart disease, cardiopulmonary exercise testing (CPET) is generally used to measure the degree of exercise intolerance [7], [8] which has been related to cardiovascular morbidity and mortality [8], [9], [10], [11], [12]. Furthermore, decreased physical fitness has been related with the incidence of hypertension in the general population [13]. However, this has not yet been investigated in patients with repaired COA.

There is a relationship between exercise-induced hypertension and sustained hypertension in adults with aortic coarctation [14]. Recently, Luijendijk et al. demonstrated that peak exercise systolic blood pressure (SBP) is predictive for the development of chronic hypertension [1]. However, their findings are based on small groups and they did not include other exercise measures.

Early identification of patients at risk for developing arterial hypertension is important in order to intensify screening strategies in subjects at the highest risk with the possibility to intervene early in the treatment of hypertension [15]. This study aimed at (1) evaluating differences in exercise responses between hypertensive and non-hypertensive patients at baseline, and (2) to assess the value of CPET to predict the development or progression of arterial hypertension.

Section snippets

Subjects

This study was designed as a multicenter retrospective study. In three European institutions, all consecutive patients with COA who were referred for CPET as part of their routine clinical follow-up were included in the study. Patients, ≥ 16 years of age at the time of the exercise test, with repaired COA with or without other small cardiac defects, which did not require an intervention (like normally functioning bicuspid aortic valve) were included. Patients with any syndrome, aberrant

Patient characteristics

In total, 223 patients who underwent surgical COA repair between 1959 and 2007 were eligible for inclusion in the study. All baseline characteristics are summarized in Table 1, and compared to a group of healthy adults of similar age and gender.

In Table 2, normotensive patients are compared with hypertensive patients. At the time of CPET, 122 patients were normotensive and 101 patients were considered hypertensive of which 61 patients were treated with antihypertensive drugs. Hypertensive

Discussion

This study showed that hypertensive patients with repaired isolated COA are older, more often male and underwent repair at older age compared to normotensive COA patients. In non-hypertensive patients with COA, a steeper VE/VCO2-slope and higher peak SBP are associated with an increased risk for the development of arterial hypertension.

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    1

    These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    2

    Contributed equally as last author.

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