Exercise Pulse Pressure Predicts Severity of

1
Exercise Pulse Pressure Predicts Severity
of Angiographically-Determined Coronary Artery
Disease Severity
Jennifer Joe, Lauren Korshak, John Peter
Kokkinos, Monica Aiken, David Lu, and Steven
Singh Veterans Affairs Medical Center,
Washington, DC, Georgetown University Medical
Center, Washington, DC
Background An insufficient rise in pulse
pressure at sub-maximal exercise may signify
hypoxia and be a stronger and clinically useful
marker for CAD severity. However, the association
between PP and severity of CAD has not been
explored.
BACKGROUND An insufficient rise in pulse
pressure (PP) at sub-maximal exercise may signify
myocardial hypoxia and be a stronger and
clinically useful marker for coronary artery
disease (CAD) severity. However, the association
between PP and severity of CAD has not been
well-defined. PURPOSE To determine the
association between exercise PP and CAD severity.
Demographics
Purpose We sought to determine the association
between pulse pressure (PP) during sub-maximal
exercise, and coronary artery disease (CAD)
severity in patients undergoing coronary
angiography.
METHODS We assessed exercise parameters and
angiographic findings in 282 patients (62 10
years) undergoing cardiac angiography subsequent
to a positive exercise tolerance test. Severe
CAD was defined as a diameter stenosis of 50
or greater in left main coronary artery 2) 70
or greater in three vessels and 3) 70 or
greater in two vessels with the proximal left
anterior descending artery involved.
Multivariate logistic regression models were
applied. Data were adjusted for age, body mass
index, cardiac medications, baseline measurements
and the conventional cardiovascular risk factors.
Method 1 Investigated measurements Exercise
blood pressure levels. Exercise
capacity. Angiographic findings . Sample 1198
male (58 11 years) undergoing an exercise
tolerance test (ETT) 282 were referred for
cardiac angiography subsequent to a positive ETT.
Predictors of CAD
RESULTS Eighty-eight (31.2) of the patients
had severe CAD and 194 (68.8) had moderate or
mild CAD. An inverse association was noted
between PP and CAD severity. More specifically,
PP lt 50 mm Hg at 3 minutes of exercise
constituted a 5.2-fold increase in the likelihood
for severe CAD (OR 5.2 CI 2.0-13.3 p
lt0.001). Furthermore, the risk of CAD severity
was reduced by 19 (OR 0.81 p 0.001) for
every 5 mm Hg increase in PP beyond this
threshold. Similarly, systolic BP at 5 METs was
also a predictor of CAD severity (OR 0.97 p
0.007). There was a 15 decrease in the risk of
CAD severity for every 5 mm Hg increase in
systolic BP at 5 METs. CONCLUSION Failure of
PP to rise above 50 mm Hg at 3 minutes of
exercise constitutes a 7-fold increase in the
likelihood of severe CAD. The risk of CAD
severity is lowered by 19 for every 5 mm Hg
increase in PP above this threshold.
Method 2 Severe CAD gt 50 stenosis in left main
coronary artery. gt 70 stenosis in three
vessels. gt 70 stenosis in two vessels with the
proximal LAD artery involved. Moderate CAD gt50
diameter stenosis in any proximal or middle
coronary artery or major branch.
Results and Conclusion PP at 3 minutes of
exercise was the best marker for CAD severity
followed by Systolic BP at 3 minutes and PP at
peak exercise.
Failure of PP to rise above 50 mm Hg at 3
minutes of exercise constitutes a 5.5-fold
increase in the likelihood of severe CAD (OR
5.5 p 0.002). The risk of CAD severity was
reduced by 15 (OR 0.85 p 0.001), for every
5 mm Hg increase in PP beyond this threshold.
Method 3 Multivariate logistic regression models
were applied. Data were adjusted for age and
body mass index. Significance of the best
diagnostic variables were tested by the
calculation of the Negelkerke's R-squared
criterion.