This thesis presents studies relating to the role of the gastrointestinal tract in postprandial blood pressure regulation. The areas that have been addressed include : ( i ) the methodological approaches to the evaluation of gastric emptying, blood pressure, splanchnic blood flow, intraluminal manometry and gut hormones and ( ii ) the pathophysiological mechanisms underlying postprandial hypotension, with a particular focus on ' gastric ' and ' small intestinal ' mechanisms and their potential therapeutic relevance. All of the studies have been either published or manuscripts have been prepared for publication. While scintigraphy represents the ' gold standard ' for the measurement of gastric emptying, recent studies suggest that three - dimensional ( 3D ) ultrasonography may also allow a precise measure of gastric emptying. Concurrent scintigraphic and ultrasonographic measurements of gastric emptying of liquids were performed in healthy young volunteers. There was a good correlation and agreement between scintigraphic measurements of gastric emptying and 3D ultrasonography after ingestion of both low - and high - nutrient drinks, indicating that 3D ultrasonography, provides a valid measure of gastric emptying of liquid meals in normal subjects. Postprandial hypotension, defined as a fall in systolic blood pressure of ≥ 20mmHg,occurring within two hours of a meal is now recognised as an important clinical problem, particularly in the elderly and in patients with type 2 diabetes. The mechanisms mediating postprandial hypotension are poorly understood. The effects of variations in concentration of intraduodenal glucose on the magnitude of the fall in blood pressure were evaluated in healthy elderly subjects. Blood pressure fell, and heart rate and blood glucose increased over time during infusions, however, there was no difference in blood pressure, heart rate or blood glucose concentrations between the study days. These observations suggest that glucose induced postprandial hypotension is a load rather, than concentration, dependent phenomenon. The effect of meal composition has been reported to influence the hypotensive response to a meal and information relating to the effects of triglyceride and protein on blood pressure is inconsistent. The comparative effects of isocaloric and isovolaemic intraduodenal infusions of glucose, triglyceride and protein on the magnitude of the postprandial fall in blood pressure and rise in heart rate and superior mesenteric artery blood flow were evaluated in healthy elderly subjects. There were comparable falls in systolic blood pressure and rises in heart rate, however, the maximum fall in systolic blood pressure occurred later after triglyceride and protein and the stimulation of superior mesenteric artery blood flow was less after protein. These observations suggest that the relatively slower systolic blood pressure response after triglyceride and protein may potentially reflect the time taken for digestion of triglyceride to free fatty acids and protein to amino acids. Acarbose is an antidiabetic drug that slows both gastric emptying and small intestinal glucose absorption. The effects of acarbose, on blood pressure, heart rate, gastric emptying of, and the glycaemic, insulin, glucagon - like peptide - 1 ( GLP - 1 ) and glucosedependent insulinotropic - polypeptide ( GIP ) responses to, an oral sucrose load were evaluated in healthy elderly subjects. Acarbose attenuated the fall in blood pressure and increase in heart rate induced by oral sucrose. Acarbose slowed gastric emptying and was associated with increased retention in the distal stomach. Stimulation of GLP - 1 may contribute to the slowing of gastric emptying and suppression of postprandial glycaemia by acarbose. These findings suggest that acarbose may represent a therapeutic option for the treatment of patients with postprandial hypotension. Recent studies indicate that gastric distension attenuates the postprandial fall in blood pressure. The effects of gastric distension on blood pressure and heart rate during intraduodenal infusion of glucose at a constant load and concentration were evaluated in healthy elderly subjects. Intragastric administration of water markedly attenuated the falls in systolic and diastolic blood pressure induced by intraduodenal glucose. Heart rate increased, with and without gastric distension, in response to intraduodenal glucose infusion but not after intraduodenal saline infusion. This study suggests that gastric distension may potentially be used as a simple adjunctive treatment in the management of postprandial hypotension. Studies employing nitric oxide synthase blockers have established, in animals, that nitric oxide mechanisms are important in the regulation of splanchnic blood flow and, hence, may effect postprandial blood pressure. The role of the nitric oxide synthase inhibitor, NG - nitro - L - arginine - methyl - ester ( L - NAME ), on gastric emptying, postprandial blood pressure, plasma insulin concentration and incretin hormone ( ie GIP and GLP - 1 ) release, following an oral glucose load, were evaluated in healthy elderly subjects. L - NAME attenuated the postprandial fall in blood pressure and increase in heart rate but had no effect on gastric emptying of glucose. L - NAME attenuated the glucose - induced rise in plasma insulin but had no effect on the incretin ( GIP and GLP - 1 ) hormone response to oral glucose. The study indicates that the magnitude of the fall in blood pressure and increase in heart rate and stimulation of insulin secretion induced by oral glucose in healthy elderly subjects are mediated by nitric oxide mechanisms by an effect unrelated to changes in gastric emptying, or the secretion of GIP and GLP - 1. Studies utilising 5 - hydroxytryptamine ( 5 - HT ) infusions in animals have demonstrated regional variations in intestinal blood flow suggesting a role for 5 - HT in postprandial haemodynamic responses. The effects of the 5 - hydroxytryptamine 3 ( 5 - HT3 ) antagonist, granisetron, on the blood pressure, heart rate, antropyloroduodenal motility and glycaemic responses to intraduodenal glucose infusion were assessed in healthy elderly subjects. Granisetron had no effect on blood pressure, heart rate or antral and pyloric motor responses but modulated the duodenal motor response, to intraduodenal glucose. This study indicates that while the cardiovascular response to intraduodenal glucose does not appear to be influenced by the stimulation of 5 - HT3 receptors, this receptor may be involved in the modulation of the duodenal motor activity. / Thesis (Ph.D.)--School of Medicine, 2006.

O pré-diabetes (PDM), da mesma forma que o diabetes mellitus (DM), associa-se com complicações micro e macrovasculares. Existem evidências de que existem anormalidades da homestoase da pressão arterial em indivíduos com PDM. Através da monitorização ambulatorial da pressão arterial (MAPA) é possível identificar o padrão de homeostase pressórica de indivíduos com diferentes graus de tolerância à glicose. Evidências demonstram que as medidas de pressão arterial (PA) obtidas por MAPA apresentam melhor associação com lesões de órgãos alvo se comparadas a medidas obtidas em consultório. Medidas de PA obtidas através de MAPA demonstram melhor correlação com complicações crônicas microvasculares do DM. Entretanto, dispõe-se de poucos dados na literatura sobre o comportamento da pressão arterial de 24 horas em indivíduos com PDM. Este trabalho é inicialmente constituído de uma revisão direcionada sobre homeostase pressórica em indivíduos com diferentes graus de tolerância à glicose seguido de um artigo original a respeito do tema. O artigo se trata de um estudo transversal que avaliou o padrão de homeostase pressórica de 24 horas em 138 indivíduos com diferentes graus de tolerância à glicose. O estudo demonstrou que através da MAPA é possível observar uma elevação dos níveis de pressão arterial ao longo de 24 horas de acordo com a piora da tolerância à glicose. / As diabetes mellitus (DM), prediabetes is associated with microvascular and macrovascular complications. There is evidence of presence of abnormalities in blood pressure (BP) homeostasis in individuals with prediabetes (PDM). Ambulatory blood pressure monitoring (ABPM) enables to identify the pattern of BP homeostasis in individuals with different degrees of glucose tolerance. Evidences have shown that BP measurements obtained by ABPM have a better association with target organ damage compared to measurements obtained in the office. Studies have also shown better correlation of BP measurements obtained by ABPM with microvascular chronic complications of DM. However, there are few data in literature about the behavior of 24 hours BP in subjects with prediabetes. This study consists of a review focused on BP homeostasis in subjects with different degrees of glucose tolerance and an original article about this issue. This is a cross-sectional study that evaluated how BP homeostasis behaves along 24 hours in 138 subjects with different degrees of glucose tolerance. The study demonstrated that through the ABPM is possible to observe an increase in blood pressure levels over 24 hours according to a worsening of glucose tolerance.

abstract: Background. Despite research aimed at understanding the mechanisms of essential hypertension, instances of this condition continue to rise. Recent findings indicate that the administration of dietary nitrates, in the form of beetroot juice and other nitrate-rich vegetables, may offer anti-hypertensive effects in various study populations. Objective. This randomized, placebo-controlled, crossover trial sought to compare the effects of high-nitrate vegetable salads to the effects of low-nitrate canned vegetables on plasma nitrate/nitrite concentration, peripheral and central-aortic systolic and diastolic blood pressures, pulse wave velocity, and flow-mediated dilation. Methods. Healthy, post-menopausal women (n=5; 80% Caucasian; 52.6 ± 5.7 years) with mildly elevated blood pressure (mean blood pressure ≥ 115/70 mm Hg and < 140/80 mm Hg) were randomly assigned to ingest a fresh, high-nitrate vegetable salad or a low-nitrate vegetable medley, twice per day, for a total of 10 consecutive days. Given the crossover design of the trial, participants observed a two to three week washout period followed by reassignment to the opposite condition. Findings were considered significant at a p-value < 0.05, and Wilcoxon Signed-Rank tests compared mean differences between conditions. Results. Plasma nitrate/nitrite concentration was significantly higher following consumption of the high-nitrate versus the low-nitrate condition (p = 0.043). Conversely, the differences in peripheral systolic and diastolic blood pressures were not statistically significant (p = 0.345 and p = 0.684 for systolic and diastolic pressures, respectively) nor were the differences in central-aortic systolic and diastolic blood pressures statistically significant (p = 0.225 and p = 0.465 for systolic and diastolic pressures, respectively). Similarly, when comparing the effects of the high-nitrate condition to the low-nitrate condition, the difference in pulse wave velocity was not statistically significant (p = 0.465). Finally, flow-mediated dilation tended to improve following consumption of the high nitrate condition (p = 0.080). Conclusion. Twice daily consumption of a fresh, high-nitrate vegetable salad significantly increased plasma nitrate/nitrite concentration. Although the trial was underpowered, there was a trend for improved flow-mediated dilation. Finally, twice daily consumption of a fresh, high-nitrate vegetable salad did not significantly lower peripheral or central-aortic systolic or diastolic blood pressures or pulse wave velocity. / Dissertation/Thesis / Masters Thesis Nutrition 2017

O pré-diabetes (PDM), da mesma forma que o diabetes mellitus (DM), associa-se com complicações micro e macrovasculares. Existem evidências de que existem anormalidades da homestoase da pressão arterial em indivíduos com PDM. Através da monitorização ambulatorial da pressão arterial (MAPA) é possível identificar o padrão de homeostase pressórica de indivíduos com diferentes graus de tolerância à glicose. Evidências demonstram que as medidas de pressão arterial (PA) obtidas por MAPA apresentam melhor associação com lesões de órgãos alvo se comparadas a medidas obtidas em consultório. Medidas de PA obtidas através de MAPA demonstram melhor correlação com complicações crônicas microvasculares do DM. Entretanto, dispõe-se de poucos dados na literatura sobre o comportamento da pressão arterial de 24 horas em indivíduos com PDM. Este trabalho é inicialmente constituído de uma revisão direcionada sobre homeostase pressórica em indivíduos com diferentes graus de tolerância à glicose seguido de um artigo original a respeito do tema. O artigo se trata de um estudo transversal que avaliou o padrão de homeostase pressórica de 24 horas em 138 indivíduos com diferentes graus de tolerância à glicose. O estudo demonstrou que através da MAPA é possível observar uma elevação dos níveis de pressão arterial ao longo de 24 horas de acordo com a piora da tolerância à glicose. / As diabetes mellitus (DM), prediabetes is associated with microvascular and macrovascular complications. There is evidence of presence of abnormalities in blood pressure (BP) homeostasis in individuals with prediabetes (PDM). Ambulatory blood pressure monitoring (ABPM) enables to identify the pattern of BP homeostasis in individuals with different degrees of glucose tolerance. Evidences have shown that BP measurements obtained by ABPM have a better association with target organ damage compared to measurements obtained in the office. Studies have also shown better correlation of BP measurements obtained by ABPM with microvascular chronic complications of DM. However, there are few data in literature about the behavior of 24 hours BP in subjects with prediabetes. This study consists of a review focused on BP homeostasis in subjects with different degrees of glucose tolerance and an original article about this issue. This is a cross-sectional study that evaluated how BP homeostasis behaves along 24 hours in 138 subjects with different degrees of glucose tolerance. The study demonstrated that through the ABPM is possible to observe an increase in blood pressure levels over 24 hours according to a worsening of glucose tolerance.

Estudo de abordagem quantitativa e delineamento quase-experimental com o objetivo de comparar os efeitos dos exercícios dinâmicos contínuo e intervalado sobre a magnitude e duração da resposta hipotensora em hipertensos. A amostra foi composta por 20 idosos hipertensos de um município do interior paulista. As variáveis estudadas foram agrupadas nas categorias: sociodemográficas, antropométricas e hemodinâmicas. Cada participante foi submetido duas sessões de exercício físico, com intervalo de uma semana entre os treinos. As sessões de exercício contínuo foram realizadas a intensidade do limiar anaeróbio. Nas sessões de exercício intervalado, os indivíduos trabalharam no limiar de compensação respiratória por 4 minutos durante a fase ativa; na fase de recuperação, trabalharam a 40% do consumo máximo de oxigênio por 2 minutos. O tempo total de cada sessão foi de 42 minutos. Para obtenção dos dados hemodinâmicos, os participantes realizaram três exames de Monitorização Ambulatorial da Pressão Arterial (MAPA), com duração de 24 horas: MAPA controle, MAPA após exercício contínuo e MAPA após exercício intervalado. As análises descritivas, com cálculo de frequências absolutas e porcentagens e descrição das médias, desvio padrão e medianas, foram realizadas por meio do pacote estatístico SPSS, versão 15.0. A descrição das diferenças proporcionais entre os grupos foi realizada primordialmente por meio de aplicação do teste estatístico não paramétrico de Wilcoxon. Em todas as análises, foi adotado o nível de significância estatística de 5% (p&lt;0,05).Quando comparamos os resultados da MAPA realizada após o exercício contínuo aos valores derivados da MAPA controle, encontramos diferença estatisticamente significante para as variáveis Pressão Arterial Sistólica (PAS) vigília (p&lt;0,001), PAS sono (p&lt;0,001), Pressão Arterial Diastólica (PAD) vigília (p&lt;0,001), PAD sono (p&lt;0,001), Pressão Arterial Média (PAM) vigília (p&lt;0,001), PAD sono (p&lt;0,001), Frequência cardíaca (FC) sono (p&lt;0,03) e Duplo Produto (DP) vigília (p&lt;0,002) e sono (p&lt;0,001), sendo que todos os índices mostraram redução após a prática do exercício contínuo. À comparação dos resultados da MAPA após exercício intervalado aos resultados da MAPA controle, constatamos que, após a prática de exercício, houve redução nos valores de PAS vigília (p&lt;0,001), PAS sono (p&lt;0,001), PAD vigília (p&lt;0,001), PAD sono (p&lt;0,001), PAM vigília (p&lt;0,001), PAM sono (p&lt;0,001) e DP vigília (p&lt;0,001) e DP sono (p&lt;0,001). Na comparação do exercício contínuo ao intervalado, encontramos diferença estatisticamente significante para as variáveis PAS vigília (p&lt;0,001) e sono (p&lt;0,01), PAD vigília (p&lt;0,001), PAM vigília (p&lt;0,001), PAM sono (p&lt;0,01), DP vigília (p&lt;0,01) e DP sono (p&lt;0,001), que se mostraram mais reduzidas após a prática do exercício intervalado. Concluímos que a prática de exercício físico contínuo e intervalado promove a hipotensão pós-exercício (HPE) ao longo das 20 horas subsequentes à atividade. O exercício intervalado gera maior magnitude de HPE e menor sobrecarga cardiovascular em comparação ao exercício contínuo. / Quantitative study with a quasi-experimental design to compare the effect of continuous and interval dynamic exercises on the magnitude and length of the hypotensive response in hypertensive patients. The sample consisted of 20 hypertensive elderly patients from a city in the interior of the State of São Paulo, Brazil. The study variables were grouped in the following categories: sociodemographic, anthropometric and hemodynamic. Each participant was submitted to two physical exercise sessions with a one-week interval between the training. The continuous exercise sessions were held at the intensity level of the anaerobic threshold. In the interval exercise sessions, the participants exercised at the respiratory compensation threshold for four minutes during the active phase; in the recovery phase, they worked at 40% of the maximum oxygen consumption for two minutes. The total length of each session was 42 minutes. To obtain the hemodynamic data, the participants undertook three outpatient Ambulatory Blood Pressure Monitoring (ABPM) tests, which took 24 hours: control ABPM, ABPM after continuous exercise and ABPM after interval exercise. For the descriptive analyses, including the calculation of absolute frequencies and percentages and the description of means, standard deviations and medians, the statistical software SPSS version 15.0 was used. The description of the proportional differences between the groups was mainly based on the application of Wilcoxon\'s non-parametric statistical test. In all analyses, statistical significance was set at 5% (p&lt;0,05).When comparing the ABPM results after continuous exercise with the results of the control ABPM, a statistically significant difference was found for the variables Systolic Blood Pressure (SBP) wake (p&lt;0.001), SBP sleep (p&lt;0.001), Diastolic Blood Pressure (DBP) wake (p&lt;0.001), DBP sleep (p&lt;0.001), Mean Blood Pressure (MBP) wake (p&lt;0.001), MBP sleep (p&lt;0.001), Heart frequency (HF) sleep (p&lt;0.03) and Double Product (DP) wake (p&lt;0.002) and sleep (p&lt;0.001). All indices showed a drop after continuous exercise. In the comparison between the ABPM results after interval exercise with the control ABPM results, after the exercise, the following levels dropped: SBP wake (p&lt;0.001), SBP sleep¬ (p&lt;0.001), DBP wake (p&lt;0.001), DBP sleep (p&lt;0.001), MBP wake (p&lt;0.001), MBP sleep (p&lt;0.001) and DP wake (p&lt;0.001) and DP sleep (p&lt;0.001). In the comparison between the continuous and interval exercises, a statistically significant difference was found for the variables SBP wake (p&lt;0.001) and sleep (p&lt;0.01), DBP wake (p&lt;0.001), MBP wake (p&lt;0.001), MBP sleep (p&lt;0.01), DP wake (p&lt;0.01) and DP sleep (p&lt;0.001), which were lower after the interval exercise sessions. In conclusion, the practice of continuous and interval physical exercise promotes post-exercise hypotension (PEH) during the 20 hours after the exercise. Interval exercises lead to a larger HPE and less cardiovascular burden in comparison with continuous exercise.

La rigidité artérielle ayant une valeur prédictive forte et indépendante d'évènements cardiovasculaires, nous émettons l'hypothèse que l'accumulation de variations de contraintes hémodynamiques altère la fonction et la structure des gros troncs artériels, indépendamment du niveau de pression artérielle. Nous avons donc mesuré l'impact de la variabilité tensionnelle sur la rigidité et la structure artérielles dans différents modèles de variabilité tensionnelle chez le rat.Chez le rat barodénervé et le rat sympathectomisé par la guanéthidine, 2 modèles de variabilité tensionnelle à court terme, une augmentation de la rigidité artérielle est associée à des altérations tissulaires différentes. En effet chez les rats barodénervés, une hypertrophie aortique est couplée à une augmentation du collagène et des attachements cellule-matrice (fibronectine et intégrine α5). Au contraire, chez les rats sympathectomisés, une hypotrophie vasculaire est associée à une diminution de l'élastine et une augmentation des attachements via l'intégrine αv.Nous avons ensuite créé, caractérisé et validé un modèle de variabilité tensionnelle à long terme, le rat spontanément hypertendu traité de façon discontinue par un antihypertenseur. Le traitement discontinu réduit la pression artérielle systolique tout en augmentant isolément la variabilité tensionnelle à long terme. La rigidité artérielle, élevée sous traitement discontinu, est associée à une hypertrophie vasculaire avec augmentation des attachements (fibronectine et intégrine αv) et sans modification du rapport élastine/collagène.En conclusion, l'élevation de variabilité tensionnelle engendre de la rigidité artérielle, et ce à pression artérielle constante. Les altérations structurales dans les modèles de variabilité tensionnelle étudiés impliquent des mécanismes différents reposant sur des modifications des relations cellule-matrice, mettant en jeu la fibronectine et les intégrines α5 et αv. / Arterial stiffness is nowadays accepted as a strong and independent predictor of cardiovascular disease. We hypothesized that increased blood pressure variability (BPV) may lead to arterial damage, independently of the blood pressure level. We thus aimed investigating the relationship between BPV and arterial stiffness and composition of the aorta in different rat models of increased BPV.In a first study performed in two models of increased short term BPV, sinoaortic denervated and chemically sympathectomized rats, an increase in wall stiffness was associated with different modifications of cell-extracellular matrix adhesion. Indeed in sinoaortic denervated rats, increased media cross-sectional area was coupled with an increased collagen content and muscle cell attachments to its cell-extracellular matrix (fibronectin and its α5β1 integrin). In contrast, chemically sympathectomized rats were characterized by a reduced media cross-sectional area associated to a reduction of elastin content and upregulation of αvβ3 integrin.In a second study, we created, characterized and validated a new experimental model of long term BPV by discontinuously treating spontaneously hypertensive rats with valsartan. Discontinuous treatment reduced systolic blood pressure level but increased long term BPV. In addition, this treatment regimen failed to reduce arterial stiffness and induced a vascular hypertrophy without modification of elastin/collagen ratio. Discontinuous treatment also highly increased vascular fibronectin in parallel to αv integrin.In conclusion, a rise of both short- and long-term BPV leads to an increase in arterial stiffness, independently of blood pressure level. The structural changes at the origin of this increase in arterial rigidity involve different mechanisms, in which fibronectin and integrin α5 and αv play a key role.

The aim of this dissertation was to address several gaps in the existing literature focused on the association between levels and variability in blood pressure (BP) and cognitive functioning. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Chapter 1 synthesizes and critically analyzes the outcomes of research reporting the association between BP variability (BPV) and cognition. Fifty-five studies met eligibility criteria, including reports measuring short-term, mid-term, and long-term BPV. Despite substantial between-study heterogeneity in study characteristics, the majority of studies reported that higher systolic BPV is associated with adverse cognitive outcomes. Further, Chapter 1 identified several gaps in the existing literature. For instance, no research has investigated the association between BPV and short-term fluctuations in cognitive functioning, or the association between mid-term BPV and concurrent cognitive functioning. Building on Chapter 1, Chapter 2 used an intensive measurement design to investigate the extent to which mid-term variability in BP, recorded using home-based BP monitoring, is associated with levels and variability in cognitive functioning in a sample of community-living older adults (N=64; Mage=70.58, SD=3.5; 77% female) assessed twice daily over a two-week period. Partial correlation coefficients estimated the association between BPV and variability in several ambulatory cognitive assessments, accounting for the learning effect during the study protocol, while multi-level models (MLMs) estimated the association between BPV and concurrent cognitive functioning. In addition, MLMs examined the extent to which BP and cognitive functioning fluctuate within and between days at the intraindividual and interindividual levels. Findings suggest that more BPV may be associated with slower or more variable reaction time, while higher BP may be associated with worse performance on accuracy tasks. / Graduate / 2022-08-30

This study was aimed at determining whether the digital volume pulse waveform using the Pulse Sensor can be used to extract features related to arterial compliance. The Pulse Sensor, a low-cost photoplethysmograph, measures green light reflection in the finger and generates output, which is indicative of blood flow and can be read by the low-cost Arduino UNO™. The Pulse Sensor code was modified to increase the sampling frequency and to capture the data in a file, which is subsequently used for waveform analysis using programs written in the R system. Waveforms were obtained using the Pulse Sensor during two 30-s periods of seated rest, in each of 44 participants, who were between the ages of 20 and 80 years. For each cardiac cycle, the first four derivatives of the waveform were calculated and low-pass filtered by convolution before every differentiation step. The program was written to extract 19 features from the pulse waveform and its derivatives. These features were selected from those that have been reported to relate to the physiopathology of hemodynamics. Results indicate that subtle features of the pulse waveform can be calculated from the fourth derivative. Feature misidentification occurred in cases of saturation or low voltage and resulted in outliers; therefore, trimmed means of the features were calculated by automatically discarding the outliers. There was a high efficiency of extraction for most features. Significant relationships were found between several of the features and age, and systolic, diastolic, and mean arterial blood pressure, suggesting that these features might be employed to predict arterial compliance. Further improvements in experimental design could lead to a more detailed evaluation of the Pulse Sensor with respect to its capability to predict factors related to arterial compliance.

Yes / Blood pressure (BP) measurement is increasingly carried out through home or ambulatory monitoring, yet existing cardiovascular risk scores were developed for use with measurements obtained in clinic. To describe differences in cardiovascular risk estimates obtained using ambulatory or home BP measurements instead of clinic readings. Design and setting: Secondary analysis of data from adults aged 30-84 without prior history of cardiovascular disease (CVD) in two BP monitoring studies (BP-Eth and HOMERUS). Method: The primary comparison was Framingham risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements. The QRISK2 and SCORE risk equations were also studied. Statistical and clinical significance were determined using the Wilcoxon signed-rank test and scatter plots respectively. Results: In 442 BP-Eth patients (mean age = 58 years, 50% female) the median absolute difference in 10-year Framingham cardiovascular risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements was 1.84% (interquartile range 0.65 to 3.63, p=0.67). Only 31/ 442 (7.0%) of patients were reclassified across the 10% risk treatment threshold. In 165 HOMERUS patients (mean age = 56 years, 46% female) the median difference in 10-year risk was 2.76% (IQR 1.19 to 6.39, p<0.001) and only 8/165 (4.8%) of patient were reclassified. Conclusion: Estimates of cardiovascular risk are similar when calculated using BP measurements obtained as in the risk score derivation study or through ambulatory monitoring. Further research is required to determine if differences in estimated risk would meaningfully influence risk score accuracy.

Arterial hypertension is one of the major treatable cardiovascular risk factors (1). It is associated with elevated mortality and the incidence of heart insufficiency, myocardial infarcts, and apolex (2). Elevated blood pressure in highperformance athletes is one of the most significant risk factors for cardiovascular diseases (3). Exaggerated blood pressure response to exercise testing is commonly regarded as a predictor of developing overt hypertension (4, 5). However, findings in adults are inconsistent (6), and no commonly accepted upper limits indicative of increased risks have been defined so far (7). There are only a few recommendations for tolerable upper blood pressure limits in exercise testing (8, 9). In the Guidelines of the European Society of Cardiology (ESC), it states that an exceeding systolic blood pressure (SB) of 210 mmHg in men and 190 mmHg in women has been termed “exercise hypertension” (7). In the American Heart Association (AHA) guideline for exercise testing (10) a limit of 214 mmHg (based on the 90th percentile calculated from >27,000 treadmill tests (11) is reported beyond which the risk of developing hypertension appears particularly increased (7). Compared to adults, the prevalence of elevated blood pressure in children and adolescents is clearly lower. However, there is a correlation between elevated blood pressure in children and relation to obesity. In contrast to the recommended upper blood pressure limits in adults, the definition of arterial hypertension in children and adults is based on body height and age-dependent limits. These blood pressure limits are determined in healthy children and adolescents. However, such blood pressure limits do not exist for young highperformance athletes, who are exposed to frequent exerciseinduced blood pressure increase. There is only limited data available in which the effects of exercise-induced blood pressure elevation have been investigated in children and adolescents. Furthermore, very little is known about the exercise-induced blood pressure response in children. The study by Wanne et al. (12) investigated the blood pressure response under maximal dynamic movement in 497 healthy 9 to 18-year-old on a treadmill in young non- athletes. They described higher systolic values in postpuberty youths than in prepuberty. Szmigielska et al. (13) examined 711 (age 10– 18 y) young athletes (training load 7.62 h ± 4.2 h per week). In the maximal testing on the bike ergometer, the SBP was significantly higher in boys than in girls (183.2 ± 27.9 mmHg vs. 170.9 ± 21.4 mmHg, p = 0.03). Description of normative response to physical exercise in healthy children and adolescents in terms of percentiles was just recently given by Sasaki et al. and Clark and al. In the study by Clarke and collegues normative percentiles of blood pressure response on a treadmill for healthy children and adolescents were described (14) in contrast to resting blood pressure and individual height which was not considered in the study by Sasaki et al. (15) Although exercise testing in young elite athletes is frequently performed during preparticipation screenings, very little is known about the “normal” magnitude and distribution of exercise-induced blood pressure in this cohort. Therefore, this study aimed to evaluate the magnitude and determinants of blood pressure response to dynamic exercise testing in young elite athletes.