Table Of ContentIngomar-Werner Franz
Ergometry in
Hypertensive Patients
Implications for Diagnosis and Treatment
Translated by TerryTelger
Foreword by P. Scholmerich
With 78 Figures and 63 Tables
Springer-Verlag
Berlin Heidelberg New York Tokyo
Prof. Dr. med. Ingomar-Werner Franz
Institut fUr Leistungsmedizin und Kardiologische Abteilung,
Klinikum Charlottenburg, Freie UniversiHit Berlin,
ForckenbeckstraBe 20, 1000 Berlin 33, BRD
Terry Telger
3429 Cloer Drive, Fort Worth
Texas 76109, USA
ISBN-13: 978-3-642-70374-4 e-ISBN-13: 978-3-642-70372-0
DOl: 10.1007/978-3-642-70372-0
Library of Congress Cataloging in Publication Data
Franz, J.-W. (Ingomar-Werner)
Ergometry in hypertensive patients. Translation of: Ergometrie bei HochdruckIq'anken.
Bibliography: p. Includes index. 1. Hypertension-Diagnosis. 2. Exercise tests. 3. Heart
function tests. 4. Treadmill exercise tests. J. Title. [DNLM: 1. Blood Pressure
Determinationinstrumentation. 2. Exertion. 3. Heart Function Testsmethods. 4.
Hypertension-diagnosis. 5. Hypertensiontherapy. WG 340 F837e]
RC685.H8F6313 1985 616.1'32'075 85-17313
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© Springer-Verlag Berlin Heidelberg 1986
Softcover reprint ofthe hardcover 1s t edition 1986
The use of general descriptive names, trade marks, etc. in this publication, even if the former
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the Trade Marks and Merchandise Marks Act, may accordingly by used freely by anyone.
Dedicated to Gaby, Thorid
Goran, Ragna
and my mother
Foreword
Within the field of general medicine, the last two decades have
seen the curative procedures increasingly supplemented by func
tions that can be summed up under the heading of "preventive
health care." There is a close link between this development and
the changing morbidity pattern. In highly developed countries
the morbidity rate attributable to infectious diseases has been
much reduced, while the various types of arteriosclerosis, some
tumorous conditions, and so-called functional syndromes have
attained massive incidence rates.
Systematic epidemiologic studies have yielded the concept of
risk factors, i. e., certain exogenous and endogenous factors
whose elimination, ideally, would make it possible to avoid the
manifestation of an illness or to ensure it did not become mani
fest until later in life or in a milder form. The socioeconomic and
sociomedical significance of these aspects is considerable, as can
be seen from all the statistics on the reasons for incapacity and
early retirement and on the relative contributions of different ill
nesses to total mortality.
Effective avoidance of illnesses by primary prophylaxis (elimi
nation of the causes of disease) or early detection of the symp
toms of disease (secondary prophylaxis) leading to early treat
ment would be a particularly significant step forward, since in
the case of most of the conditions mentioned above only pallia
tive forms of treatment are available, and none that have any cu
rative effect.
Attempts to apply sound knowledge collected in epidemiolog
ic studies in practical programs are certainly fraught with diffi
culties. These lie in the varying degrees of health.consciousness,
with social-class-specific gradations in the intensity of utilization
of the prophylactic facilities available, especially while there are
no symptoms to justify a visit to the doctor. The problems are al
so concerned with the cost·benefit ratio, however; if screening is
not performed in a controlled manner it can lead to cost escala
tions that can hardly be supported, while a more favourabel cost
benefit ratio is possible when risk groups can be identified. Fi
nally, however, there are still numerous difficulties in the assess
ment of the findings from the viewpoint of diagnosis and prog-
VIII Foreword
nostic significance. This applies particularly to one of the most
effective risk factors in the pathogenesis of arteriosclerosis, viz.
arterial hypertension. Epidemiologic data suggest that at least
10% of the adult population is affected, and that only a quarter
of those affected receive adequate treatment. The most common
reason for this is that people are unaware of their hypertension.
The evaluation of the values obtained on measurement of arteri
al pressure is also not a simple matter. Variations in the blood
pressure at rest, different limit values separating normal from
elevated pressure, and different recommendations for treatment
on the basis of these undermine the confidence of both patient
and the doctor.
This is the first point of departure of the present work, which
allows a nicer differentiation of the areas of normal pressure,
borderline hypertension, and definite hypertension by applying
graduated levels of physical stress.
The varying reactions to physical stress in different patient
groups give information that is useful in assessment of the prog
nosis and the same time cast new light on some aspects of thera
py. It has been shown in the present study that conventional anti
hypertensive agents do not by any means lower the resting blood
pressure and the blood pressure on exertion in the same way. Fi
nally, ergometric stress can also be used as a model for the evalu
ation of stress-dependent metabolic processes and hormonal
reactions. This allows a better understanding of some of the side
effects of the therapeutic agents used so that they can be more
easily avoided.
The sociomedical significance of the conclusions, drawn from
the findings recorded in a large number of subjects, is high. In
addition, the examination procedure is universally applicable,
does not take up much time, and can also be justified from the
cost angle.
The panel of judges appointed by the Hufeland Award Foun
dation sees this volume as an important contribution to prophy
lactic health care, and has proposed that it be recognized as the
prizewinning work of 1981. The Board of Governors of the
Hufeland Award Foundation has accepted this proposal, there
by continuing their tradition of over 20 years' standing of honor
ing newly recognized and scientifically sound truths that can be
applied in practical ways in the sector of health care.
P. Scholmerich
Hufeland Award Foundation
Preface
Blood pressure, the central parameter in the diagnosis of arterial
hypertension, is a highly variable quantity. It can fluctuate mark
edly with the time of day and with the momentary physical and
emotional state of the individual. This raises two fundamental
problems with regard to the clinical assessment of arterial hyper
tension. First, it is apparent that the detection and evaluation of
blood pressure in the office setting can be an extremely difficult
matter, and that the WHO criteria for classifying patients as hy
pertensive, borderline hypertensive and normotensive are largely
arbitrary. This particularly applies to the diagnosis of borderline
hypertension, juvenile labile hypertension, and age-linked blood
pressure elevations.
Second, the resting blood pressure does not reflect the exces
sive blood pressure increases that may occur in response to
everyday stresses. The nature of these elevations appears to be
important in determining the severity of hypertensive complica
tions. They have a bearing not only on the progression of cardio
vascular complications, but also on the danger of acute myocar
dial events in hypertensive patients with occult or overt coronary
heart disease, since an excessive stress-induced rise of blood
pressure greatly increases the myocardial oxygen demand.
The evaluation of high blood pressure would be greatly facili
tated by a standardized test procedure that would enable com
parable and reproducible blood pressure determinations to be
made. It would also be useful to have a standardized method for
monitoring sympathetic activity so that the occurrence and mag
nitude of inordinate stress responses could be more accurately
assessed.
One way of meeting these requirements is through standard
ized ergometric testing. Owing to its good reproducibility, er
gometry is widely used to evaluate cardiocorporeal performance
in sports and occupational medicine, as well as for detecting cor
onary heart disease in the hospital or office setting.
When one considers the good standardizability and conve
nience of ergometry on the one hand, and the formidable diag
nostic problems involved in the evaluation of high blood pres
sure on the other, ergometry appears to be a rational technique
X Preface
for the diagnosis of hypertension. Because hypertension is so
prevalent, such a method can be of practical value only if it relies
on relatively simple equipment and is well tolerated by the pat
ient. Moreover, a single examination should not be so cost-inten
sive that it would prohibit serial testing, nor so time-consuming
that it would preclude routine outpatient examinations.
One of the main goals of this book, therefore, is to establish
whether indirect blood pressure determinations made during
and after standardized ergometric exercise can discriminate be
tween an arbitrarily defined normal and pathologic resting
blood pressure, and thus facilitate evaluation, and also whether
ergometric data are of value in the early recognition of hyperten
sive disease, the assessment of its severity, and the selection of
patients for drug therapy. In answering these questions, it will be
necessary to address three main aspects:
1. Does ergometric testing facilitate the assessment of borderline
hypertension?
2. Does ergometry facilitate the evaluation of marginally to mild
ly elevated blood pressures in the elderly?
3. Is the blood pressure response to ergometry of prognostic sig-
nificance in arterial hypertension?
A positive answer to these three questions would be of major rel
evance to preventive medicine and public health, for it would fa
cilitate the selection of patients for antihypertensive therapy,
which in tum could prevent or at least delay the onset of serious
sequelae. This assumes particular significance in the light of re
cent U. S. and Australian intervention studies which showed a
significant reduction of mortality over a five-year period in mild
ly hypertensive patients who received antihypertensive treat
ment.
The importance of arterial hypertension as a risk factor and
the severity of its vascular complications are determined not only
by the level of the resting blood pressure, but also by the magni
tude, frequency and duration of blood pressure elevations that
are elicited by ordinary physical and emotional stresses. Given
the frequency of these stress responses, a central goal of antihy
pertensive therapy must be to alter these responses in such a way
as to relieve the burden on the cardiovascular system. Thus~ anti
hypertensive agents must lower not only the resting blood pres
sure but also the transient elevations of blood pressure which ac
company physical and emotional stresses - a goal that is not re
alized in all cases. In the second part of the book, therefore, the
following questions are addressed:
1. Do different beta-blocking agents, administered in equivalent
doses, influence the rise of blood pressure during ergometry to
an equal degree, and do they differ in their duration of action?
Preface XI
2. Do diuretics, calcium antagonists and beta-blocking agents
which lower the blood pressure at rest have similar effects on
blood pressure elevations during ergometry?
3. Do diuretics and calcium antagonists enhance the antihyper
tensive effect of beta-blocking agents and may they be used in
combination with them?
4. Is the combined use of diuretics and beta-blocking agents a ra
tional treatment for hypertension in the elderly?
5. How is the increased myocardial oxygen consumption in hy
pertensive patients, and the associated risk of myocardial in
farction as well as fatal hypoxia-induced arrhythmias, influ
enced by different modes of therapy?
6. Do endurance training and weight reduction have a salutary
effect on hypertension, and what possibilities, positive or neg
ative, are offered by sport?
The resolution of these questions is of major practical impor
tance, for it would facilitate the treatment of arterial hyperten
sion, improve the efficacy of treatment, and also affirm the need
to consider the pressor effects of environmental stresses when
developing a treatment strategy.
I.-W.Franz
Table of Contents
I. Methodology ....... . 1
1. Principles of Ergometry 1
1.1. Methodologic Principles 1
1.1.1. Physical Principles . . . . . . . 1
1.1.2. Exercise Stages and Workload Increments. . 2
1.1.3. Standards for Ergometric Testing . . . . . . . 5
1.2. Physiology and Pathophysiology of Ergometry . 6
1.2.1. Hemodynamic Changes . 6
1.2.2. Arterial Wall Changes . . . . . . . . . . . . . . . 7
2. Blood Pressure Measurement during Ergometry 8
2.1. Study Population . . . . . . .. 8
2.2. Test Methodology . . . . . . . . . . . . . . 8
2.2.1. The Ergometer . . . . . . . . . . . . . . . . 8
2.2.2. Exercise Stages and Workload Increments . 9
2.3. Heart Rate Measurement . . . . . . . . . . 10
2.4. Blood Pressure Measurement . . . . . . . . 10
2.5. Comparison of Direct and Indirect Blood Pressure
Measurements . . . . . . . . . . . . . . . . . . . . 11
2.6. Environmental Specifications and Test Preparations 14
II. Ergometry as an Aid to Diagnosis 15
1. Statement of Problem . . . . . 15
2. Blood Pressure and Heart Rate Responses of Normal
Individuals . . . . . . . . . . . . . . . . . . . . . . .. 20
2.1. Blood Pressure Responses of Men 20-50 Years of Age 20
2.1.1. Study Population ......... 20
2.1.2. Resting Blood Pressure . . . . . . . . . . . .. 22
2.1.3. Blood Pressure during Ergometry . . . . .. 23
2.1.4. Blood Pressure during Recovery . . . . . . 23
2.1.5. Heart Rate before, during and after Ergometry . . 24
2.2. Blood Pressure and Heart Rate Responses of Men
55-80 Years of Age ................. 25
Description:Within the field of general medicine, the last two decades have seen the curative procedures increasingly supplemented by func tions that can be summed up under the heading of "preventive health care." There is a close link between this development and the changing morbidity pattern. In highly dev
