Thanks for chiming in @dtoce. So it sounds like you wouldn't be comfortable ruling out CAD based on the tests results I have (EKG and MIBI) and that the Coronary Calcium Screening would be more definitive.

My LDL levels (3.19 mmol/L) did not seem problematic, and I think that, coupled with being younger and fitter than the vast majority of patients in the cardio clinic, led the cardiologist to focus his attention on the more obvious red flag of the exercise-induced hypertension. I do worry that the evidence seems to suggest that any exercise I've been doing has resulted in unsafe blood pressure levels (the ST-depression occured at 150bpm, which is Zone 2 for me - I'll hold that for hours and hours at a time. A one hour race effort would see me average 180bpm) well exceeding 200, and over the years I feel like atherosclerosis would be a logical consequence of this. Hence CAD seems like it would still be a concern despite what the cardiologist seems to be saying.


So the exercise-induced hypertension, while problematic, may not be the whole story, and a Calcium Scan would be a good idea to see if there really is any CAD going on. Is that an accurate assessment?


I'm on 40mg of Azilsartan now - is it reasonable to expect that this might help the exercise-induced hypertension, or is that only really going to drop my resting blood pressure down a few points? Dropping resting BP down from 138 to 128, for example, is all well and good, but if my BP at aerobic paces drops from 220 to 210, that doesn't really solve my problem.

I am just trying to help explain testing and treatment options as well as concerns-

SBP greater than 210 on an exercise treadmill test is considered an 'exaggerated BP response'. It is often a sign of pre-HTN.
I do not know if you do or don't have HTN-that is between you and your doctors-as well as whether you should be on ARB or amlodipine, which I often use in athletes with HTN.

and at 44 years, it would be really unusual to have CAD/plaque (a non 0 number on a coronary calcium score-a 1 would put you in the 75th percentile--that's bad...).
It is more likely to have a false positive ETT....just sayin'



Good luck.

Thanks Monty. From my interactions with the medical community over the years, I definitely agree with this take. Hoping I can connect with a doctor more familiar with endurance athletes.

Hi ClayDavis,

First - I've been a member for years (maybe a decade now?) but have probably done less than half a dozen posts because I never really have anything to say or ask. But I do think I should chip in here.

I'm a practicing physician, and whilst I'm not a cardiologist by trade I spent multiple years doing post-fellowship training in echocardiography, and am doing my PhD in cardiopulmonary interactions in well/unwell people. This involves doing maximal effort cardiopulmonary exercise tests (CPET, or CPX, depending on which continent you originate from) as part of my clinical practice and my research. These are full dataset (ie all the gas exchange data + BP + 12 lead ECG + oximetry, etc - some clinics that do VO2 max testing don't capture all of that). I won't bore you with the details except to point out a couple of things about that blood pressure response you mentioned:

1. Depending on how it was measured, the potential error in the BP numbers you were told is mmmmaaaassssssssssiiiivvvveeeee. If it was done manually it relies on a person hearing the relevant Korotkoff sounds, and we aren't particularly good at doing that especially when the numbers are really high (that is both BP numbers and HR numbers). If it was done by a machine - they are even dodgier. Not to mention issues with cuff sizing versus your arm size. It sounds like you've had a dobutamine stress echo and a MIBI (you mentioned stress echo with the contrast so you may have meant exercise stress echo with ultrasound contrast such as Definity or similar to get better quality pictures). If you had an actual exercise test on a bike or treadmill then it is far far harder to properly appreciate the real BP.

If you had an arterial line in place and it was properly zeroed - then we'd know what your true BP was.

2. BP is meant to go up with exercise, and there is older data that proposes a rough guide as to what that should be (e.g. 10-20mmHg systolic per MET, or similar depending on what you read). But if you are doing a test that isn't accurately determining workload (i.e. MET) even these rough numbers are harder to apply.

3. We don't actually really know what is 'too high' with exercise. Again, different guidelines, written by different boffins, typically from different continents, all have slightly different values as to what the upper limit of acceptable is. But where did those values come from? 200 sounds like a high number for BP and we get scared about it, but there is no good quality dataset out there that says what is normal. There are datasets of many thousands of people for BP at rest, but such things do not exist for people at maximal intensity exercise.

If I stopped people when they got their BP to 200, or 220, or any other number you choose - I would be doing a lot of submaximal tests. If people have an exagerrated BP response based on trajectory, e.g. goes from 120 at rest to 200 at minimal exercise: that's a different story. But if BP goes up somewhat linearly with workload then that is probably fine: at least there is no data to say it isn't.

(usual "I'm not your doctor, your mileage may vary, don't take medical advice from randoms on the internet" disclaimer to the above)

This is an excellent post on so many levels. On behalf of all, thank you for weighing in. You, and dtoce are much appreciated.

The initial recommendations to @ClayDavis sounded odd. It is incumbent on medical providers to understand their own limits and be humble enough to explore or seek additional input when providing advice, especially when it has major life altering implications.

Really interesting, thanks @ben_guts. Fwiw yes they did it manually (though I thought it was weird the cuff directly over the iv rather than up on the bicep).

I'm trying to get a referral to a sports cardiology clinic now.