Inverse association of pulse pressure augmentation during exercise with heart failure and death

Mahmoud Al Rifai, Michael Blaha, Faisal Rahman, Jonathan K. Ehrman, Clinton A. Brawner, Steven J. Keteyian, Mouaz H. Al-Mallah, John William McEvoy

Research output: Contribution to journalArticle

Abstract

Objective: Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. Methods: The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. Results: Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51% were men and 29% black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0-2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95% CI 1.1 to 1.5) for quartile 2 and 1.5 (95% CI 1.2 to 1.8) for quartile 1, p for trend<0.001) and mortality (aHR of 1.1 (95% CI 1.01 to 1.2) for quartile 2 and 1.3 (95% CI 1.2 to 1.5) for quartile 1, p for trend<0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. Conclusions: Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.

Original languageEnglish (US)
JournalHeart
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Heart Failure
Exercise
Blood Pressure
Myocardial Infarction
Metabolic Equivalent
Mortality
Proportional Hazards Models
Heart Rate

Keywords

  • death
  • exercise
  • heart failure
  • pulse pressure
  • risk factor

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Al Rifai, M., Blaha, M., Rahman, F., Ehrman, J. K., Brawner, C. A., Keteyian, S. J., ... McEvoy, J. W. (Accepted/In press). Inverse association of pulse pressure augmentation during exercise with heart failure and death. Heart. https://doi.org/10.1136/heartjnl-2018-313736

Inverse association of pulse pressure augmentation during exercise with heart failure and death. / Al Rifai, Mahmoud; Blaha, Michael; Rahman, Faisal; Ehrman, Jonathan K.; Brawner, Clinton A.; Keteyian, Steven J.; Al-Mallah, Mouaz H.; McEvoy, John William.

In: Heart, 01.01.2018.

Research output: Contribution to journalArticle

Al Rifai, Mahmoud ; Blaha, Michael ; Rahman, Faisal ; Ehrman, Jonathan K. ; Brawner, Clinton A. ; Keteyian, Steven J. ; Al-Mallah, Mouaz H. ; McEvoy, John William. / Inverse association of pulse pressure augmentation during exercise with heart failure and death. In: Heart. 2018.
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abstract = "Objective: Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. Methods: The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. Results: Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51{\%} were men and 29{\%} black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0-2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95{\%} CI 1.1 to 1.5) for quartile 2 and 1.5 (95{\%} CI 1.2 to 1.8) for quartile 1, p for trend<0.001) and mortality (aHR of 1.1 (95{\%} CI 1.01 to 1.2) for quartile 2 and 1.3 (95{\%} CI 1.2 to 1.5) for quartile 1, p for trend<0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. Conclusions: Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.",
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AU - Al Rifai, Mahmoud

AU - Blaha, Michael

AU - Rahman, Faisal

AU - Ehrman, Jonathan K.

AU - Brawner, Clinton A.

AU - Keteyian, Steven J.

AU - Al-Mallah, Mouaz H.

AU - McEvoy, John William

PY - 2018/1/1

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N2 - Objective: Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. Methods: The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. Results: Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51% were men and 29% black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0-2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95% CI 1.1 to 1.5) for quartile 2 and 1.5 (95% CI 1.2 to 1.8) for quartile 1, p for trend<0.001) and mortality (aHR of 1.1 (95% CI 1.01 to 1.2) for quartile 2 and 1.3 (95% CI 1.2 to 1.5) for quartile 1, p for trend<0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. Conclusions: Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.

AB - Objective: Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. Methods: The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. Results: Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51% were men and 29% black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0-2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95% CI 1.1 to 1.5) for quartile 2 and 1.5 (95% CI 1.2 to 1.8) for quartile 1, p for trend<0.001) and mortality (aHR of 1.1 (95% CI 1.01 to 1.2) for quartile 2 and 1.3 (95% CI 1.2 to 1.5) for quartile 1, p for trend<0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. Conclusions: Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.

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