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Medical blog about stress testing: PMC response

H Robert Silverstein, MD, gives his response to an article in forums on Medscape – unfortunately, we are unable to find the original forum posting, but the text is provided below.

Original forum posting
————————————-
Elevated Blood Pressure Response to Exercise

I just performed a screening cardiac stress test on a 48 year old male
as part of a corporate medical exam. The patient had not seen a
physician in over 15 years for a full check-up and reported being in
good health. He says he has been a runner for twenty years and has never
had any problems. He has no history of HTN or heart dz and there is no
FH of heart dz or HTN. His resting BP was 120/80 and his cardiac exam
was negative.

His cardiac stress test was interpretted as negative for ischemic
changes but I stopped his stress test @ about 81% exertion because his
BP shot up to 220/80. He was feeling fine, but I didn’t want to push him
any further because of the extremely high BP made me nervous !! His
cooldown was rapid and he felt fine throughout the test. I am wondering
what should be done for this patient ? Should I have him see a
cardiologist ? Should I have him see his internist or GP to discuss
putting him on BP medication to temper his BP response to exercise ?? If
this was your patient and he presented to your office reporting this
information to you ( ie. the stress test report), what would you do ?? I
am posting this on cardiology to get their opinion, too..

H Robert Silverstein‘s response:
————————————————

This case is not all that unusual. In fact, it is common. Those
commentors above who have discussed stiff arterial blood vessels have
the right idea. There are several instruments that look at this with
great facility, the one most commonly used is the Sphygmocor. It
calculates the “augmentation index” which, as implied several times
above, is the reflected vascular wave back from stiff peripheral blood
vessels. To me, this man, unlikely has any significant (75% stenoses)
coronary artery disease. However, this stress test was not 100% or even
“adequate” in the sense that he did not achieve even 85% of predicted
maximum heart rate. Regardless, he has atherosclerotic stiffening of
his blood vessels, and his risks need to be identified/treated. I would
not recommend an echo or nuclear stress tests. I would recommend
obtaining his non-HDL cholesterol which should be 90 or less,
triglycerides, which should be less than 100, homocysteine which should
be midrange, Lp (a) midrange, Cardiac CRP (despite the recent press, I
believe that it is valuable)= 1, A1C 5.5. His BP should be checked
(despite caveats to the contrary, I believe the Omron wrist BP cuffs are
the best/most portable, most reasonable especially with the high
frequency of excessively large arm size of so many) in what I call the
“9 time zones” of the day = before and after each meal, middle of the
morning/afternoon/bed time @ the rate of 2 recordings/day so that the BP
is documented for the entire day time over the course of 4-5 days.
Getting a BP during the night is going a bit far. To summarize, to me
he has evidence hardening of the arteries, his risks need to be
identified, and ideally treated with more of a whole foods diet such as
brown rice/vegetables/beans/some fruits, a small amount of nuts and
seeds and palm sized animal protein perhaps twice a week. If medicines
are necessary to achieve these goals, then so be it. a juried article I
read documented that alpha lipoic + acetyl L-carnitine softened the
vessels & improved vascular reactivity/wave form. Likewise, pomegranete
has some information to substantiate that it may have a beneficial
effect on atherosclerosis regression. Since he is a man, I believe he
should be evaluated for cancer of the prostate with a PSA/digital rectal
examination. Stool bloods should be checked for fecal globin with tests
such as Insure or Colocare or FOB Advanced. All risks need to be
attended to, as best possible. Our website is: www.thepmc.org.
Oobviously, the patient is “free to choose.” Everything I have said,
is an “invitation to consider.” I have no vested/conflicts of interest.
H Robert Silverstein, MD, FACC, Medical Director, Preventive Medicine
Center.

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H. Robert Silverstein does two television shows on cable access television in the Hartford area. Here's where you can find more of his show videos and a schedule for their airing:

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