Long-term follow-up after aortic coarctation repair: The unsolved issue of exercise-induced hypertension

INTRODUCTION: Despite successful repair of aortic coarctation (AC), systemic hypertension (HTN) can persist in a significant percentage of patients. Exercise-induced HTN is also common in these patients, although its clinical significance is still unclear. In this study we aimed to assess the prevalence of exercise-induced HTN in adult patients with repaired AC. METHODS: We retrospectively reviewed the clinical records of patients aged >18 years with repaired AC followed at an adult congenital heart disease outpatient clinic in a tertiary care center. Demographic and clinical data including age at intervention, blood pressure (BP) at rest and on exercise, transthoracic echocardiogram (TTE) and treadmill exercise test results were evaluated. Exercise-induced HTN was defined as peak systolic BP ≥ 210 mmHg for men and ≥ 190 mmHg for women. RESULTS: We analyzed 65 patients (40 [61.5%] male; mean age at follow-up 30 ± 8 years). Median age at AC repair was 7 years (P25-P75: 4-20) and mean follow-up was 20 ± 7 years. Only one patient had diabetes and 10 (15.4%) had dyslipidemia. The majority of patients had controlled BP at rest and only nine (18%) were under antihypertensive medication. Forty-nine patients performed a treadmill exercise test. The mean duration of exercise was 10.7 ± 3.1 minutes and mean peak heart rate was 166 ± 18 beats per minute. Eleven (22%) patients had a hypertensive response, among whom only three (33%) had uncontrolled BP at rest. In our study treatment with angiotensin-converting enzyme inhibitors (ACEI) (OR 4.0 [95% CI 1.9-18.1]) and the peak instantaneous gradient in the descending aorta by TTE (OR 8.2 [95% CI 1.8-37.0]) were predictors of a hypertensive response with exercise. Age at surgery and type of AC repair were not associated with a hypertensive response on exercise. CONCLUSIONS: In this study we found a significant prevalence of exercise-induced HTN in adult patients after successful AC repair despite adequate BP control at rest. Exercise-induced HTN was significantly related to higher peak gradient in the descending aorta and treatment with ACEI. These results highlight the complexity of the adult AC population and show that, even after a good surgical result, several patients remain at high cardiovascular risk and require long-term follow-up.