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CLINICAL STUDY: MYOCARDIAL DISEASE

Hemodynamic determinants of exercise-induced abnormal blood pressure response in hypertrophic cardiomyopathy

Quirino Ciampi, MD^*, Sandro Betocchi, MD, FACC^*,*, Raffaella Lombardi, MD^*, Fiore Manganelli, MD^*, Giovanni Storto, MD, Maria Angela Losi, MD^*, Elpidio Pezzella, MD^*, Filippo Finizio, MD^*, Alberto Cuocolo, MD and Massimo Chiariello, MD, FACC^*

^* Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Naples, Italy
Department of Morphological and Functional Sciences, "Federico II" University School of Medicine, Naples, Italy

Manuscript received October 24, 2001; revised manuscript received April 8, 2002, accepted April 19, 2002.

^* Reprint requests and correspondence: Dr. Sandro Betocchi, Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University School of Medicine, Via S. Pansini 5, Naples, I-80131 Italy.
sandro.betocchi{at}unina.it

OBJECTIVES: We sought to assess the hemodynamics of exercise in patients with hypertrophic cardiomyopathy (HCM), with and without an exercise-induced abnormal blood pressure (BP) response, by ambulatory radionuclide monitoring of left ventricular (LV) function with the VEST device (Capintec Inc., Ramsey, New Jersey).

BACKGROUND: Blood pressure fails to increase >20 mm Hg during exercise in about one-third of patients with HCM. This carries a high risk of sudden death.

METHODS: Forty-three patients with HCM and 14 control subjects underwent maximal symptom-limited exercise on a treadmill during VEST. The VEST data were averaged for 1 min and analyzed at baseline, 3 min and peak exercise. The LV end-diastolic, end-systolic and stroke volumes, cardiac output and systemic vascular resistance were expressed as the percentage of baseline.

RESULTS: Ejection fraction and stroke volume fell in patients with HCM, although they increased in control subjects (p < 0.001 and p = 0.002, respectively). Cardiac output increased significantly more in control subjects than in patients with HCM (p = 0.001). In 17 patients with HCM (39%) with an abnormal BP response, ejection fraction and stroke volume fell more (p = 0.032 and p = 0.009, respectively) and cardiac output increased less (p = 0.001) than they did in patients with HCM with a normal BP response. Systemic vascular resistance decreased similarly in patients with HCM, irrespective of the BP response.

CONCLUSIONS: In patients with HCM with and without an abnormal BP response, abnormal hemodynamic adaptation to exercise was qualitatively similar but quantitatively different. An abnormal BP response was associated with exercise-induced LV systolic dysfunction. This causes hemodynamic instability, associated with a high risk of sudden cardiac death.

Abbreviations and Acronyms   ANOVA   analysis of variance   BP   blood pressure   ECG   electrocardiogram   HCM   hypertrophic cardiomyopathy   LV   left ventricular   VEST   ambulatory radionuclide monitoring device

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