arthyperАртериальная гипертензия"Arterial’naya Gipertenziya" ("Arterial Hypertension")1607-419X2411-8524Antihypertensive League10.18705/1607-419X-2020-26-6-648-655arthyper-1984Research ArticleСтатьиArticlesГипертензивная реакция на нагрузку: распространенность и влияние на результаты стресс-эхокардиографииHypertensive response to exercise: prevalence and impact on stress echocardiography resultshttps://orcid.org/0000-0002-2176-4611КаревЕ. А.KarevE. A.

Карев Егор Андреевич — врач функциональной диагностики, врач-кардиолог 

ул. Аккуратова, д.2, Санкт-Петербург, 197341

Egor A. Karev, MD, Functional Diagnostics Specialist, Cardiologist

2 Akkuratov street, St Petersburg, 197341

karev_ea@almazovcentre.ruhttps://orcid.org/0000-0002-6035-9344ВербилоС. Л.VerbiloS. L.

Вербило Сергей Леонидович —врач функциональной диагностики, врач-кардиолог

Санкт-Петербург

Sergey L. Verbilo, MD, Functional Diagnostics Specialist, Cardiologist

St Petersburg

verbilo_sl@almazovcentre.ruhttps://orcid.org/0000-0002-6168-8895МалевЭ. Г.MalevE. G.

Малев Эдуард Геннадиевич — доктор медицинских наук, ведущий научный сотрудник научно-исследовательской лаборатории соединительнотканных дисплазий Института сердца и сосудов

Санкт-Петербург

Eduard G. Malev, MD, PhD, DSc, Leading Researcher, Research Laboratory for Connective Tissue Dysplasia, Heart and Vessels Institute

St Petersburg

malev@almazovcentre.ruhttps://orcid.org/0000-0003-4360-7622ПрокудинаМ. Н.ProkudinaM. N.

Прокудина Мария Николаевна —доктор медицинских наук, врач-кардиолог, президент

Санкт-Петербург

Maria N. Prokudina, MD, PhD, DSc, Cardiologist, President

St Petersburg

info@corspb.ruФедеральное государственное бюджетное учреждение «Национальный медицинский исследовательский центр имени В.А. Алмазова» Министерства здравоохранения Российской ФедерацииРоссияAlmazov National Medical Research CenterRussian FederationОбщество с ограниченной ответственностью «Международный центр сердца»РоссияInternational Heart CenterRussian Federation202006092020266648655Copyright © Карев Е.А., Вербило С.Л., Малев Э.Г., Прокудина М.Н., 20212021Карев Е.А., Вербило С.Л., Малев Э.Г., Прокудина М.Н.Karev E.A., Verbilo S.L., Malev E.G., Prokudina M.N.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://htn.almazovcentre.ru/jour/article/view/1984

Актуальность. Гипертензивная реакция артериального давления (АД) на нагрузку (ГРН) имеет существенное прогностическое значение, являясь предиктором развития у пациента гипертонической болезни и церебральных сосудистых событий. Литературные данные о влиянии ГРН на результаты стрессэхокардиографии (стресс-ЭхоКГ) противоречивы. Цель исследования — оценить частоту возникновения ГРН при проведении стресс-ЭхоКГ на тредмиле у пациентов с известной ишемической болезнью сердца или подозрением на нее и влияние ГРН на результаты исследования. Материалы и методы. Были проанализированы результаты 3434 стресс-ЭхоКГ тестов, выполненных в амбулаторном порядке в течение периода 1 месяца (21.01–21.02) каждого года за период с 2007 до 2020 годы. Были изучены частота возникновения ГРН в ходе стресс-ЭхоКГ исследования и взаимосвязь гипертензивной реакции с положительным результатом исследования. Результаты. Распространенность ГРН у пациентов, которым была выполнена стресс-ЭхоКГ в разные годы, составила от 8,6% до 41,5% (в среднем за 14 лет — 23,2%), при этом в период с 2015 по 2020 годы доля тестов с ГРН снизилась. Среди пациентов с ГРН положительный тест встречался чаще, чем среди пациентов с адекватной реакцией АД: 40,6 % против 31,0 % (r = 12,2, р = 0,0005). Выводы. Наличие взаимосвязи между реакцией АД на нагрузку и результатами стресс-ЭхоКГ говорит о влиянии ГРН на результаты исследования и необходимости тщательного подбора антигипертензивной терапии перед исследованием.

Background. Hypertensive response of blood pressure (BP) to exercise has substantial prognostic impact. Hypertensive response to exercise is shown to be a predictor for development of hypertension and stroke. The data concerning hypertensive response to exercise influence on stress echocardiography results are controversial. Objective. The aim of the study was to assess the frequency of hypertensive response of BP to exercise and its impact on the result of the stress echocardiography on treadmill in patients with known or suspected ischemic heart disease. Design and methods. We analyzed 3434 tests performed in out-patient department during 1 month period (21.01–21.02) of every year since 2007 to 2020. We studied the occurrence of hypertensive response to exercise during exercise stress echocardiography on treadmill and its relation to positive results of the test. Results. The prevalence of hypertensive response to exercise varied from 8,6 % to 41,5 % (average in 14-year period — 23,24%), however, the proportion of tests with hypertensive response to exercise significantly declined in the period from 2015 to 2020 years. Patients with hypertensive response to exercise showed significantly more frequent positive tests in comparison to patients with normotensive BP response: 40,6 % vs 31,0% (r = 12,2, р = 0,0005), though yearly analysis showed no correlation between the number of tests with hypertensive response to exercise and number of positive tests (r = 0,21; р = 0,47). Conclusions. Significant correlation between BP response and stress echocardiography results means that hypertensive response to exercise has an impact on the test results, therefore antihypertensive treatment optimization is essential before test.

стресс-эхокардиографияартериальная гипертензиягипертензивная реакция на нагрузкуstress-echocardiographyhypertensionhypertensive response to exerciseReferencesChow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. J Am Med A. 2013;310(9):959–968. doi:10.1001/jama.2013.184182.Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A et al. Prevalence, awareness, treatment, and control of hypertension inrural and urban communities in high-, middle-, and low-income countries. JAMA 2013;310:959–968. DOI: 10.1001/jama.2013.184182Ерина А. М., Ротарь О. П., Солнцев В. Н., Шальнова С.А., Деев А. Д., Баранова Е.И. и др. Эпидемиология артериальной гипертензии в Российской Федерации — важность выбора критериев диагностики. Кардиология. 2019;59(6):5–11. [Erina AM, Rotar OP, Solntsev VN, Shalnova SA, Deev AD, Baranova EI et al. Epidemiology of arterial hypertension in Russian Federation —importance of choice of criteria of diagnosis. Kardiologiia. 2019;59(6):5–11. In Russian]. doi:10.18087/cardio.2019.6.2595Ерина А.М., Ротарь О.П., Солнцев В.Н., Шальнова С.А., Деев А.Д., Баранова Е.И. и др. Эпидемиология артериальной гипертензии в Российской Федерации – важность выбора критериев диагностики. Кардиология. 2019;59(6):5-11. [Erina A.M., Rotar O.P., Solntsev V.N., Shalnova S.A., Deev A.D., Baranova E.I. et al. Epidemiology of Arterial Hypertension in Russian Federation – Importance of Choice of Criteria of Diagnosis. Kardiologiia. 2019;59(6):5-11. In Russian] doi: 10.18087/cardio.2019.6.2595.Артериальная гипертензия у взрослых. Клинические рекомендации 2020. Российский кардиологический журнал. 2020;25(3):3786. doi:10.15829/1560-4071-2020-3-3786 [Arterial hypertension in adults. Clinical guidelines 2020. Russ J Cardiol. 2020;25(3):3786. In Russian].Артериальная гипертензия у взрослых. Клинические рекомендации 2020. Российский кардиологический журнал. 2020;25(3):3786. doi:10.15829/1560-4071-2020-3-3786 [Arterial hypertension in adults. Clinical guidelines 2020. Russian Journal of Cardiology 2020;25(3):3786. In Russian]Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39(33). doi:10.1093/eurheartj/ehy339Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) European Heart Journal 2018;39(33) https://doi.org/10.1093/eurheartj/ehy339Holmqvist L, Mortensen L, Kanckos C, Ljungman C, Mehlig K, Manhem K. Exercise blood pressure and the risk of future hypertension. J Hum Hypertens. 2012;26(12):691–695. doi:10.1038/jhh.2011.99Holmqvist L, Mortensen L, Kanckos C, Ljungman C, Mehlig K, Manhem K. Exercise blood pressure and the risk of future hypertension. J Hum Hypertens 2012;26:691–695. DOI: 10.1038/jhh.2011.99Lauer MS, Levy D, Anderson KM, Plehn JF. Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study. Ann Intern Med. 1992;116(3):203–210. doi:10.7326/0003-4819-116-3-203Lauer MS, Levy D, Anderson KM, Plehn JF. Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study. Ann Intern Med. 1992;116(3):203-10. doi: 10.7326/0003-4819-116-3-203Weiss SA, Blumenthal RS, Sharrett AR, Redberg RF, Mora S. Exercise blood pressure and future cardiovascular death in asymptomatic individuals. Circulations. 2010;121(19):2109–2116. doi:10.1161/CIRCULATIONAHA.109.895292Weiss SA, Blumenthal RS, Sharrett AR, Redberg RF, Mora S. Exercise blood pressure and future cardiovascular death in asymptomatic individuals. Circulation. 2010;121(19):2109-16. doi: 10.1161/CIRCULATIONAHA.109.895292Balogun MO, Sulyman BO, Akinwusi PO. A comparison of the cardiovascular responses to treadmill and bicycle ergometer exercise in healthy male Nigerians. Afr J Med Med Sci. 1997;26 (1–2):27–30.Balogun MO, Sulyman BO, Akinwusi PO. A comparison of the cardiovascular responses to treadmill and bicycle ergometer exercise in healthy male Nigerians. Afr J Med Med Sci. 1997;26(1-2):27‐30.Yadav A, Bagi J. A study to evaluate cardiovascular responses by using treadmill and ergometer bicycle exercise in young adults. Indian J Health Sciences Biomedical Res (KLEU). 2018;11:81–85. doi:10.4103/kleuhsj.kleuhsj_89_17Yadav, A., Bagi, J. A study to evaluate cardiovascular responses by using treadmill and ergometer bicycle exercise in young adults. Indian Journal of Health Sciences and Biomedical Research (KLEU) 2018;11:81-85. doi;10.4103/kleuhsj.kleuhsj_89_17Tanaka H, Bassett DR, Michael J. Turner exaggerated blood pressure response to maximal exercise in endurance-trained individuals. Am J Hypertens. 1996;9(11):1099–1103. doi:10.1016/0895-7061(96)00238-5Tanaka H., David R. Bassett, Jr., Michael J. Turner Exaggerated Blood Pressure Response to Maximal Exercise in Endurance-Trained Individuals. American Journal of Hypertension 1996; 9(11):1099–1103 https://doi.org/10.1016/0895-7061(96)00238-5Allison TG, Cordeiro MA, Miller TD, Daida H, Squires RW, Gau GT. Prognostic significance of exercise-induced systemic hypertension in healthy subjects. Am J Cardiol. 1999;83(3):371–375. doi:10.1016/s0002-9149(98)00871-6Allison TG, Cordeiro MA, Miller TD, Daida H, Squires RW, Gau GT. Prognostic significance of exercise-induced systemic hypertension in healthy subjects. Am J Cardiol. 1999;83(3):371-5. DOI: 10.1016/s0002-9149(98)00871-6Abram S, Arruda-Olson AM, Scott CG, Pellikka PA, Nkomo VT, Oh JK et al. Typical blood pressure response during dobutamine stress echocardiography of patients without known cardiovascular disease who have normal stress echocardiograms. Eur Heart J Cardiovasc Imaging. 2015;17(5):557–556. doi:10.1093/ehjci/jev165Abram S, Arruda-Olson AM, Scott CG, Pellikka PA, Nkomo VT, Oh JK et al. Typical blood pressure response during dobutamine stress echocardiography of patients without known cardiovascular disease who have normal stress echocardiograms. Eur Heart J Cardiovasc Imaging 2015;17:557-6 DOI: 10.1093/ehjci/jev165Tsumura K, Hayashi T, Hamada C, Endo G, Fujii S, Okada K. Blood pressure response after two-step exercise as a powerful predictor of hypertension: the Osaka Health Survey. J Hypertens. 2002;20(8):1507–1512. doi:10.1097/00004872-200208000-00012Tsumura K, Hayashi T, Hamada C, Endo G, Fujii S, Okada K Blood pressure response after two-step exercise as a powerful predictor of hypertension: the Osaka Health Survey. J Hypertens. 2002;20(8):1507-12. DOI: 10.1097/00004872-200208000-00012Manolio TA, Burke GL, Savage PJ, Sidney S, Gardin JM, Oberman A. Exercise blood pressure response and 5-year risk of elevated blood pressure in a cohort of young adults: the CARDIA study. Am J Hypertens. 1994;7(3):234–241. doi:10.1093/ajh/7.3.234Manolio TA, Burke GL, Savage PJ, Sidney S, Gardin JM, Oberman A. Exercise blood pressure response and 5-year risk of elevated blood pressure in a cohort of young adults: the CARDIA study. Am J Hypertens. 1994;7(3):234-41. DOI: 10.1093/ajh/7.3.234Filipovský J, Ducimetière P, Safar ME. Prognostic significance of exercise blood pressure and heart rate in middleaged men. Hypertension. 1992;20(3):333–339. doi:10.1161/01.hyp.20.3.333Filipovský J, Ducimetière P, Safar ME. Prognostic significance of exercise blood pressure and heart rate in middle-aged men. Hypertension. 1992;20(3):333-9. DOI: 10.1161/01.hyp.20.3.333Miyai N, Arita M, Morioka I, Miyashita K, Nishio I, Takeda S. Exercise blood pressure response in subjects with high-normal blood pressure: exaggerated blood pressure response to exercise and risk of future hypertension in subjects with high-normal blood pressure. J Am Coll Cardiol. 2000;36(5):1626–1631. doi:10.1016/s0735-1097(00)00903-7Miyai N, Arita M, Morioka I, Miyashita K, Nishio I, Takeda S. Exercise BP response in subjects with high-normal BP: exaggerated blood pressure response to exercise and risk of future hypertension in subjects with high-normal blood pressure. J Am Coll Cardiol. 2000;36(5):1626-31. DOI: 10.1016/s0735-1097(00)00903-7Wilson MF, Sung BH, Pincomb GA, Lovallo WR. Exaggerated pressure response to exercise in men at risk for systemic hypertension. Am J Cardiol. 1990;66(7):731–736. doi:10.1016/0002-9149(90)91139-wWilson MF, Sung BH, Pincomb GA, Lovallo WR. Exaggerated pressure response to exercise in men at risk for systemic hypertension. Am J Cardiol. 1990;66(7):731-6. DOI: 10.1016/0002-9149(90)91139-wMizuno R, Fujimoto S, Saito Y, Yamazaki M. Clinical importance of detecting exaggerated blood pressure response to exercise on antihypertensive therapy. Heart. 2016;102(11):849–854. doi:10.1136/heartjnl-2015-308805Mizuno R, Fujimoto S, Saito Y, Yamazaki M Clinical importance of detecting exaggerated blood pressure response to exercise on antihypertensive therapy. Heart. 2016;102(11):849-54. DOI: 10.1136/heartjnl-2015-308805Stewart KJ, Sung J, Silber HA, Fleg JL, Kelemen MD, Turner KL et al. Exaggerated exercise blood pressure is related to impaired endothelial vasodilator function. Am J Hypertens. 2004;17(4):314–320. doi:10.1016/S0895-7061(03)01003-3Stewart KJ, Sung J, Silber HA, Fleg JL, Kelemen MD, Turner KL et al. Exaggerated exercise blood pressure is related to impaired endothelial vasodilator function. Am J Hypertens. 2004;17(4):314-20. DOI: 10.1016/S0895-7061(03)01003-3Tzemos N, Lim PO, Mackenzie IS, MacDonald TM. Exaggerated exercise blood pressure response and future cardiovascular disease. J Clin Hypertens (Greenwich). 2015;17(11):837–844. doi:10.1111/jch.12629.Tzemos N, Lim PO, Mackenzie IS, MacDonald TM. Exaggerated Exercise Blood Pressure Response and Future Cardiovascular Disease. J Clin Hypertens (Greenwich). 2015;17(11):837-44. DOI: 10.1111/jch.12629Jae SY, Fernhall B, Heffernan KS, Kang M, Lee MK, Choi YH et al. Exaggerated blood pressure response to exercise is associated with carotid atherosclerosis in apparently healthy men. J Hypertens. 2006;24(5):881–887. doi:10.1097/01.hjh.0000222758.54111.e2Jae SY, Fernhall B, Heffernan KS, Kang M, Lee MK, Choi YH et al. Exaggerated blood pressure response to exercise is associated with carotid atherosclerosis in apparently healthy men. J Hypertens. 2006;24(5):881-7. doi: 10.1097/01.hjh.0000222758.54111.e2.Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Systolic blood pressure response to exercise stress test and risk of stroke. Stroke. 2001;32(9):2036–2041. doi:10.1161/hs0901.095395Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Systolic blood pressure response to exercise stress test and risk of stroke. Stroke. 2001;32(9):2036-41. doi: 10.1161/hs0901.095395.Prada-Delgado O. Prognostic value of exercise-induced left ventricular systolic dysfunction in hypertensive patients without coronary artery disease. Rev Esp Cardiol. 2015;68(2):107–114. doi:10.1016/j.rec.2014.03.023Prada-Delgado O. Prognostic Value of Exercise-induced Left Ventricular Systolic Dysfunction In Hypertensive Patients Without Coronary Artery Disease. Rev Esp Cardiol 2015;68(2):107-14. doi: 10.1016/j.rec.2014.03.023.Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measurements at rest and during exercise in hypertensive men. Hypertension. 1996;28(1):31–36. doi:10.1161/01.hyp.28.1.31Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measurements at rest and during exercise in hypertensive men. Hypertension. 1996; 28(1):31-6. doi: 10.1161/01.hyp.28.1.31.Thanassoulis G, Lyass A, Benjamin EJ, Larson MG, Vita JA, Levy D et al. Relations of exercise blood pressure response to cardiovascular risk factors and vascular function in the Framingham Heart Study. Circulation. 2012;125(23):2836–2843. doi:10.1161/CIRCULATIONAHA.111.063933Thanassoulis G, Lyass A, Benjamin EJ, Larson MG, Vita JA, Levy D et al. Relations of exercise blood pressure response to cardiovascular risk factors and vascular function in the Framingham Heart Study. Circulation. 2012;125(23):2836-43. doi: 10.1161/CIRCULATIONAHA.111.063933.Shim CY, Ha JW, Park S, Choi EY, Choi D, Rim SJ et al. Exaggerated blood pressure response to exercise is associated with augmented rise of angiotensin II during exercise. J Am Coll Cardiol. 2008;52(4):287–292. doi:10.1016/j.jacc.2008.03.052Shim CY, Ha JW, Park S, Choi EY, Choi D, Rim SJ et al. Exaggerated blood pressure response to exercise is associated with augmented rise of angiotensin II during exercise. J Am Coll Cardiol. 2008;52(4):287-92 doi: 10.1016/j.jacc.2008.03.052.Tzemos N, Lim PO, MacDonald TM. Is exercise blood pressure a marker of vascular endothelial function? QJM: International J Med. 2002;95(7):423–429. doi:10.1093/qjmed/95.7.423Tzemos N, Lim PO, MacDonald TM. Is exercise blood pressure a marker of vascular endothelial function? QJM: An International Journal of Medicine. 2002;95(7):423–429 https://doi.org/10.1093/qjmed/95.7.423Jae SY, Fernhall B, Lee M, Heffernan KS, Lee MK, Choi YH et al. Exaggerated blood pressure response to exercise is associated with inflammatory markers. J Cardiopulm Rehabil. 2006;26(3):145–149. doi:10.1097/00008483-200605000-00005Jae SY, Fernhall B, Lee M, Heffernan KS, Lee MK, Choi YH et al. Exaggerated blood pressure response to exercise is associated with inflammatory markers. J Cardiopulm Rehabil. 2006;26(3):145-9. doi: 10.1097/00008483-200605000-00005.Fagard R, Staessen J, Thijs L, Amery A. Prognostic significance of exercise versus resting blood pressure in hypertensive men. Hypertension. 1991;17(4):574–578. doi:10.1161/01.hyp.17.4.574Fagard R, Staessen J, Thijs L, Amery A. Prognostic significance of exercise versus resting blood pressure in hypertensive men. Hypertension. 1991 ;17(4):574-8. doi: 10.1161/01.hyp.17.4.574.Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measurements at rest and during exercise in hypertensive men. Hypertension. 1996;28(1):31–36. doi:10.1161/01.hyp.28.1.31Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measurements at rest and during exercise in hypertensive men. Hypertension. 1996;28(1):31-6. doi: 10.1161/01.hyp.28.1.31.Donal E, Bergerot C, Thibault H, Ernande L, Loufoua J, Augeul L et al. Influence of afterload on left ventricular radial and longitudinal systolic functions: a two-dimensional strain imaging study. Eur J Echocardiogr. 2009;10(8):914–921. doi:10.1093/ejechocard/jep095Donal E, Bergerot C, Thibault H, Ernande L, Loufoua J, Augeul L et al. Influence of afterload on left ventricular radial and longitudinal systolic functions: a two-dimensional strain imaging study. Eur J Echocardiogr 2009;10:914 doi: 10.1093/ejechocard/jep095.Ha J, Juracan E, Mahoney D, Oh JK, Shub C, Seward JB et al. Hypertensive response to exercise: a potential cause for new wall motion abnormality in the absence of coronary artery disease. J Am Coll Cardiol. 2002;39(2):323–327. doi:10.1016/s0735-1097(01)01743-0Ha J, Juracan E, Mahoney D, Oh JK, Shub C, Seward JB et al. Hypertensive response to exercise: a potential cause for new wall motion abnormality in the absence of coronary artery disease. J Am Coll Cardiol. 2002;39:323-327 doi: 10.1016/s0735-1097(01)01743-0.Mottram PM, Haluska B, Yuda S, Leano R, Marwick TH. Patients with a hypertensive response to exercise have impaired systolic function without diastolic dysfunction or left ventricular hypertrophy. J Am Coll Cardiol. 2004;43(5):848–853. doi:10.1016/j.jacc.2003.08.057Mottram PM, Haluska B, Yuda S, Leano R, Marwick TH. Patients with a hypertensive response to exercise have impaired systolic function without diastolic dysfunction or left ventricular hypertrophy. J Am Coll Cardiol. 2004;43(5):848-53. doi: 10.1016/j.jacc.2003.08.057.Shin JH, Shiota T, Kim YJ, Kwan J, Qin JX, Eto Y et al. False-positive exercise echocardiograms: impact of sex and blood pressure response. Am Heart J. 2003;146(5):914–919. doi:10.1016/S0002-8703(03)00410-1Shin JH, Shiota T, Kim YJ, Kwan J, Qin JX, Eto Y et al. False-positive exercise echocardiograms: impact of sex and blood pressure response. Am Heart J. 2003;146(5):914-9. doi: 10.1016/S0002-8703(03)00410-1.Jurrens TL, From AM, Kane GC, Mulvagh SL, Pellikka PA, McCully RB. An exaggerated blood pressure response to treadmill exercise does not increase the likelihood that exercise echocardiograms are abnormal in men or women. J Am Soc Echocardiogr. 2012;25(10):1113–1119. doi:10.1016/j.echo.2012.07.001Jurrens TL, From AM, Kane GC, Mulvagh SL, Pellikka PA, McCully RB. An exaggerated blood pressure response to treadmill exercise does not increase the likelihood that exercise echocardiograms are abnormal in men or women. J Am Soc Echocardiogr. 2012;25(10):1113-9 doi: 10.1016/j.echo.2012.07.001.Abram S, Arruda-Olson A, Scott C, Pellikka P, Nkomo V, Oh J et al. Frequency, predictors, and implications of abnormal blood pressure responses during dobutamine stress echocardiography. Circ Cardiovasc Imaging. 2017;10: e005444. doi:10.1161/CIRCIMAGING.116.005444Abram S, Arruda-Olson A, Scott C, Pellikka P, Nkomo V, Oh J et al. Frequency, predictors, and implications of abnormal blood pressure responses during dobutamine stress echocardiography. Circ Cardiovasc Imaging 2017;10:e005444 DOI: 10.1161/CIRCIMAGING.116.005444Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR et al. Guidelines for performance, interpretation, and application of stress echocardiography in ischemic heart disease: From the American Society of Echocardiography. J Am Soc Echocardiogr. 2020;33(1):1–41.e8. doi:10.1016/j.echo.2019.07.001Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR et al. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr. 2020;33(1):1-41.e8. doi: 10.1016/j.echo.2019.07.001.From AM, Kane G, Bruce C, Pellikka PA, Scott C, McCully RB. Characteristics and outcomes of patients with abnormal stress echocardiograms and angiographically mild coronary artery disease (< 50 % stenoses) or normal coronary arteries. J Am Soc Echocardiogr. 2010;23(2):207–14.126. doi:10.1016/j.echo.2009.11.023From AM, Kane G, Bruce C, Pellikka PA, Scott C, McCully RB. Characteristics and outcomes of patients with abnormal stress echocardiograms and angiographically mild coronary artery disease (<50% stenoses) or normal coronary arteries. J Am Soc Echocardiogr 2010;23:207-14.126. doi: 10.1016/j.echo.2009.11.023.

The authors declare that there are no conflicts of interest present.