Circulation, Vol 84, 686-696, Copyright © 1991 by American Heart Association
PJ Counihan, MP Frenneaux, DJ Webb and WJ McKenna
BACKGROUND. Exercise hypotension has been documented in hypertrophic
cardiomyopathy. It is not the result of an inability to augment cardiac
output but instead relates to an inappropriate and exaggerated decrease in
systemic vascular resistance at high work loads. METHODS AND RESULTS. To
enable us to examine the behavior of the peripheral vasculature during
exercise, 103 consecutive patients underwent maximal symptom-limited supine
bicycle exercise with measurement of forearm blood flow. A minimum
reduction of 12% from the basal value was defined as a normal response
based on the study of 25 normal controls. In the patients, two patterns of
forearm blood flow were observed. Sixty-four patients had an appropriate
reduction in forearm blood flow of 40 +/- 16% from resting flow. In 39
patients, the forearm blood flow either failed to decrease or increased
with exercise by 45 +/- 105% of the resting value. Patients with an
abnormal forearm vasodilator response were younger (31 +/- 13 versus 46 +/-
14 years), and more of them had a family history of hypertrophic
cardiomyopathy and sudden death than did those with a normal
vasoconstrictor response (16 of 39 versus eight of 64). Left ventricular
end-diastolic cavity dimensions were smaller in those with an abnormal
forearm blood flow response, but other clinical, echocardiographic, and
arrhythmic variables were similar. To assess the relation of abnormal
peripheral vascular responses to erect exercise blood pressure response,
patients underwent treadmill exercise testing with careful monitoring of
systolic blood pressure response. Thirty- eight patients had significant
exercise hypotension with failure of the systolic blood pressure to
increase during progressive exercise (n = 6) or an abrupt decrease in
systolic blood pressure (20-60 mm Hg) from the peak value (n = 32); 65
patients had a normal exercise blood pressure response, but 18 of these
patients had an oscillation in systolic blood pressure of 10 mm Hg or more
early in the recovery phase. Thirty-one of 39 patients with an abnormal
forearm blood flow response demonstrated exercise hypotension during the
erect exercise testing, and the remaining eight patients had a normal
exercise blood pressure response; however, five of these eight had abnormal
oscillations in blood pressure during recovery (r = 0.61, p less than
0.001). CONCLUSIONS. The relation of abnormal peripheral vascular responses
to exercise hypotension confirms the observation of hemodynamic instability
in patients with hypertrophic cardiomyopathy. The finding of abnormal
vascular responses in patients known to be at increased risk (young age and
a family history of hypertrophic cardiomyopathy and sudden death) suggests
that hemodynamic mechanisms may be important in the occurrence of sudden
death in hypertrophic cardiomyopathy.
ARTICLES
Abnormal vascular responses to supine exercise in hypertrophic cardiomyopathy
Department of Cardiological Sciences, St. George's Hospital Medical School, London, UK.
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