Physicians' Academy for Cardiovascular Education

Novel exercise parameter inversely associated with risk of HF and mortality

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

Literature - Al Rifai M, Blaha MJ, Rahman F et al. - Heart 2018;0:1–6. doi:10.1136/heartjnl-2018-313736

Introduction and methods

In individuals with suspected coronary artery disease (CAD), resting peak exercise values for systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP) are measured during stress testing, however, the significance of PP augmentation in response to exercise remains relatively unknown [1]. Previous studies showed a lower PP rise with exercise among individuals with a history of anterior myocardial infarction (MI) [2] or mortality [1]. However, these data did not account for resting PP and did not include data on non-fatal outcomes like heart failure (HF). Therefore, this study assessed the relationship between the novel exercise parameter - pulse pressure stress index (P2SI) - and incident HF, MI and all-cause mortality among participants of the Henry Ford ExercIse Testing (FIT) Project.

The FIT project is a large, real-world cohort study consisting of patients aged >18 years who underwent physician-referred treadmill stress testing at Henry Ford Health System-affiliated hospitals and ambulatory care centers in Detroit, Michigan between 1991 and 2009. Subjects with a history of CAD, HF or atrial fibrillation (AF), and those below the 1st or above the 99th percentile of P2SI were excluded, leaving a study population of 55,524 participants.

PP was measured as the difference between SBP and DBP, respectively, and P2SI was defined as PP peak exercise during stress testing divided by resting PP. Participants were divided into quartiles according to their P2SI variability: Q1 (0.90-1.59 mmHg), Q2 (1.60-1.95 mmHg), Q3 (1.96-2.37 mmHg) and Q4 (2.38-4.09 mmHg).

The primary outcomes of the study were all-cause mortality, MI and incident HF.

Main results


In a large cohort study, poor augmentation of PP with exercise was inversely associated with risk of HF and all-cause mortality in individuals with suspected CAD, with a useful and simple threshold of <1.96 mmHg to identify incident HF and all-cause mortality. These results show that P2SI can be considered as a novel and readily quantifiable high-risk feature derived from exercise stress testing, which may be applied to any patient. Further research is needed to validate this new clinical parameter.


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Find this article online at BMJ Heart

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