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ISSN: 1064-1963 (print), 1525-6006 (electronic)

Clin Exp Hypertens, 2014; 36(1): 9–16

! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/10641963.2013.783047

ORIGINAL ARTICLE

The relationship between exercise capacity and masked hypertension

in sedentary patients with diabetes mellitus
Hakan Akilli1, Mehmet Kayrak1, Alpay Arıbas1, Mehmet Tekinalp1, Selim Suzi Ayhan2, Mehmet Gündüz1,
Hajrudin Alibasic1, Gokhan Altunbas1, and Mehmet Yazıcı1
1
Department of Cardiology, Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey and 2Department of Cardiology, Abant Izzet
Baysal University, Faculty of Medicine, Bolu, Turkey
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Abstract Keywords
Aim: Although exaggerated blood pressure responses (EBPR) to exercise have been related to Diabetes mellitus, exercise treadmill test,
future hypertension and masked hypertension (MHT), the relationship between exercise exercise capacity, masked hypertension,
capacity and MHT remains unclear. A sedentary life style has been related to increased sedentary lifestyle
cardiovascular mortality, diabetes mellitus (DM), and hypertension. In this study, we aimed to
examine the relationship between exercise capacity and MHT in sedentary patients with DM. History
Methods: This study included 85 sedentary and normotensive patients with DM. Each patient’s
daily physical activity level was assessed according to the INTERHEART study. All patients Received 3 November 2012
underwent an exercise treadmill test, and exercise duration and capacity were recorded. Blood Revised 30 November 2012
pressure (BP) was recorded during all exercise stages and BP values 200/110 mmHg were Accepted 28 February 2013
accepted as EBPR. MHT was diagnosed in patients having an office BP 5140/90 mmHg and Published online 17 May 2013
For personal use only.

a daytime ambulatory BP 4135/85 mmHg. Patients were divided into two groups according
to their ambulatory BP monitoring (MHT and normotensive group).
Results: The prevalence of MHT was 28.2%. Exercise duration and capacity were lower in the
MHT group than in the normotensive group (p50.05) and were negatively correlated with age,
HbA1c, mean daytime BP, and mean 24 hour BP. Peak exercise systolic BP and the frequency
of EBPR were both increased in the MHT group (25.0% and 8.1%, respectively, p ¼ 0.03).
According to a multivariate regression, exercise capacity (OR: 0.61, CI95%: 0.39–0.95, p ¼ 0.03),
EBPR (OR: 9.45, CI95%: 1.72–16.90, p ¼ 0.01), and the duration of DM (OR: 0.84, CI95%:
0.71–0.96, p ¼ 0.03) were predictors of MHT.
Conclusion: Exercise capacity, EBPR, and the duration of DM were predictors of MHT in
sedentary subjects with DM.

Introduction MHT (6–10). Some studies have used the exercise treadmill
test (ETT) to evaluate DM and non-DM patients for MHT and
The combination of diabetes mellitus (DM) and hypertension
have found that an exaggerated blood pressure response to
(HT) is associated with high mortality rates due to cardio-
exercise (EBPR) is a determinant of future HT and MHT.
vascular events (1). Masked hypertension (MHT), diagnosed
in patients with office blood pressures (BP) 5140/90 mmHg
However, the relationship between exercise capacity and 14
20
MHT remains unclear (11,12).
and daily mean ambulatory BP 4135/85 mmHg (2), is related
Sedentary lifestyle is an important public health problem
to target organ damage, sustained HT, and increased cardio-
that is often neglected. Seven percent of DM cases and 6% of
vascular mortality (3,4). While the incidence of MHT is
coronary heart cases can be attributed to a sedentary lifestyle
between 7% and 17% in the general population (5), the
(13,14). However, studies of patients with sedentary lifestyles
incidence rate for MHT in DM patients has been reported to
have been extremely limited. Most studies investigating the
be as high as 47% (1). Due to its prevalence, close association
relationship between MHT and EBPR have not assessed
with other risk factors, and adverse cardiovascular events,
the daily physical activity levels of the patients. These studies
MHT can be defined as a major health problem (6). As a
enrolled a heterogeneous patient group including both
result, many studies have investigated the determinants of
sedentary and/or physically active subjects. As a result, the
current literature yields contradictory results regarding the
exercise capacity of patients with MHT (15). Also, the role
of exercise capacity in predicting MHT remains unclear.
Correspondence: Hakan Akilli, M.D., Necmettin Erbakan Universitesi
In the present study, we aimed to investigate the relationship
Meram Tip Fakultesi Kardiyoloji Sekreterligi, Meram, 42090 Konya,
Turkey. Tel: 0090-332-2237941. Fax: 0090-332-2236181. E-mail: between exercise capacity and MHT in a homogeneous group
hakanakilli@hotmail.com including sedentary patients with type 2 DM.
 10 H. Akilli et al.
Methods
Study population
Three hundred eighty-seven consecutive type 2 DM patients
who presented to the outpatient department of cardiology
and diabetes were prospectively evaluated for this study.
Patients diagnosed with DM who had BP 5140/90 mmHg,
who were living sedentary lifestyles, who had used anti-
diabetic drugs for more than 6 months, and who had not
used any antihypertensive medications were included in this
study. This study was approved by the ethics committee, and
informed consent was obtained from each patient.
Exclusion criteria
Patients with coronary artery disease, heart failure, moderate–
severe heart valve pathology, office systolic BP (SBP)
140 mmHg, office diastolic BP (DBP) 90 mmHg, a history
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of HT or antihypertensive treatment administered for any
reason (e.g. palpitations, beta blockers due to arrhythmia,
angiotensin-converting enzyme inhibitors for renal protection,
diuretics due to edema), atrial fibrillation, a left bundle branch
block, those having a pacemaker, orthopedic problems, or a
systemic disease that would prevent completion of an ETT
(e.g. chronic obstructive pulmonary disease, renal failure)
were excluded from the study. Patients over 70 years of age
and patients who refused to participate in the study were also
excluded.
For personal use only.
Sedentary lifestyle
A questionnaire was used to evaluate the physical activity
levels of the patients during their work and free time.
Employed patients were divided into four groups based on
their work-related activity levels: mainly sedentary, predom-
inantly walking on flat terrain, often walking uphill or lifting
heavy objects and heavy physical labor. Leisure-time activity
levels of unemployed patients were also taken into account
and evaluated. Leisure-time activity levels were divided into
four groups according to their responses: mainly sedentary
(sitting, reading, watching television), mild exercise (minimal
effort activities such as yoga, relaxed walking or fishing),
moderate exercise (moderate effort activities such as walking,
bicycle riding or light gardening at least 4 hours/week),
and strenuous exercise (rapid heart rate activities such as
football, running and vigorous swimming) (16). All employed
patients were included in the study regardless of their level
of activity, but only the sedentary unemployed patients were
included.
Study protocol
Patients who participated in the study were evaluated during
two visits on consecutive days.
First visit: Office BP was measured, and each patient
provided a detailed medical history and completed a seden-
tary lifestyle questionnaire. Exclusion criteria were evaluated,
and anthropometric characteristics (height, weight and waist
and hip circumferences) were measured. Body mass index
(BMI) was calculated as weight (kg)/height (m)2. Ninety-
three patients who fit the inclusion criteria were asked to
return for a second visit after fasting for 12 hours.
Clin Exp Hypertens, 2014; 36(1): 9–16
Second visit: Office BP was re-measured. Three patients
with an office BP 140/90 mmHg were excluded from the
study. Blood samples were collected for routine biochemical
tests after 12 hours of fasting, and 60 minutes after consuming
a light breakfast, patients underwent an ETT. An ETT was
given 1 day before the ambulatory blood pressure measure-
ments (ABPM) performance test in order to prevent the
patients from making more of an effort during the ETT after
being encouraged by the researchers. This effort increased the
reliability of the study. As a result of the second visit, a total
of 85 patients (male: 50, female: 35, mean age: 50.58.1
years) were enrolled in the study. Figure 1 depicts the patient
flow chart.
Office blood pressure measurements
At both visits, the BP of each patient was measured by a nurse
following a 10 minute rest in a sitting position, and after
3 minutes, it was measured again by a doctor. Resting BP
was measured with a mercury sphygmomanometer (ERKA,
Kallmeyer Medizintechnik GmbP Co. KG, Bad Tolz,
Germany) over the brachial artery. The appropriate cuff size
was used for each patient. A total of four average measure-
ments were taken during both visits, and the baseline SBP
and DBP values were determined. All of the mean office
BP values for the patients included in this study were below
140/90 mmHg.
Exercise treadmill testing
Following a 10 minutes rest, BP and basal heart rate was
recorded for each patient. The exercise test was performed
using an electrocardiography system and a treadmill inte-
grated with a computer (Model 770 M, RAM Medical and
Industrial Instruments & Supply, Padova, Italy) following the
standard Bruce protocol. Twelve-lead electrocardiographic
recordings were taken before the test, at the end of each three
minute stage, at peak exercise capacity, and during the 3rd
minutes of the recovery period. SBP and DBP were non-
invasively recorded with an automated BP monitor
(Tango þ Stress BP, Sun Tech Medical Inc., Morrisville,
NC) immediately before testing (while the subjects were still
sitting) and during the last 30 seconds of each 3 minutes
exercise stage. At the end of the study, BP was measured
during the 3rd minute of the recovery phase while the subjects
were in a sitting position. Based on the BP response, the test
was evaluated to be either normal or EBPR. The test was
evaluated as EBPR if the SBP was over 200 mmHg or the
DBP was over 100 mmHg at peak exercise capacity (17). The
peak exercise time was recorded in minutes. Exercise capacity
was measured in metabolic equivalents (METs). ETT termin-
ation criteria were as follows: (1) shortness of breath or
fatigue preventing the continuation of the ETT, (2) chest
discomfort, or (3) a horizontal or down-sloping ST depression
of more than 1 mm.
Ambulatory blood pressure monitoring
Nearly all of the ABPM were collected a day after the ETT
(n ¼ 82). Twenty-four hour ABPMs were performed using
a non-invasive automatic device (Tracker NIBP2, Del Mar
Reynolds Ltd, Hertford, England). The cuff was fitted to
 DOI: 10.3109/10641963.2013.783047
Figure 1. Patient flowchart. DM: Diabetes
mellitus, BP: Blood pressure, COPD:
Chronic obstructive pulmonary disease, ETT:
Exercise treadmil test, ABPM: Ambulatuary
blood pressure monitoring.
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each patient’s non-dominant arm, and the device was
programmed to take a measurement every 20 minutes
during the day and every 30 minutes at night. Recordings
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for each subject were accepted if more than 80% of the raw
data were valid. Average values were calculated for two
periods in a single day: a six-hour period between 1 AM and
6 AM (nighttime) and a 12-hour period between 9 AM and
9 PM (daytime).
Blood analysis
Blood samples were taken during the second visit after
12 hours of fasting. Blood samples were analyzed for fasting
plasma glucose, total cholesterol, triglycerides, high density
lipoprotein cholesterol (HDL-C), creatinine, complete blood
count and HbA1c. Biochemical and hematologic parameters
were measured using an Olympus AU 600 auto-analyzer
(Olympus Optical Co., Ltd., Schimatsu-Mishima, Japan)
and a Bayer Advia 120 CBC counter (New Jersey, USA).
Total cholesterol, triglycerides, and HDL-C were analyzed
enzymatically with a Hitachi 747 analyzer (Japan). Low
density lipoprotein cholesterol (LDL-C) was calculated using
the Friedewald formula (18), while creatinine clearance was
calculated with the Cockroft–Gault formula (19).
Statistical analysis
All statistical analyses were performed using SPSS software
version 15.0 (SPSS, Chicago, IL). Data were presented as
mean  SD. The distribution for each variable was analyzed
using the Kolmogorov–Smirnov test. The Pearson’s correl-
ation test was used for normally distributed variables while
the Spearman correlation test was used for nonparamterically
distributed variables. The relationship between categorical
variables was determined using the 2-test. Independent
student’s t tests were used for comparing differences between
two groups of normally distributed variables, while Mann
Exercise capacity in predicting masked hypertension 11
Whitney U tests were used for comparing differences between
two groups of non-parametrically distributed variables. A
multiple stepwise logistic regression analysis was performed
to detect the predictors of MHT using the backward elimin-
ation method. The elimination criterion was defined as
having a probability above 0.10. The following covariates
were entered into the regression model: age, gender, BMI,
total cholesterol, HbA1C, duration of DM (years), office
SBP, exercise duration, exercise capacity, EBPR status and
SBP at peak exercise.
A power analysis was performed using the Minitab 16
packet program. The sample volume was calculated as 85 to
determine the difference between MET and other values.
The MedCalc 9.2.0.1 packet program was used to obtain
receiver operating curves (ROC) and to determine the
specificity, sensitivity, and negative and positive predictive
values for the exercise capacity and exercise duration
parameters associated with MHT.
Results
Eighty-five sedentary patients with type 2 DM who had
resting BP 5140/90 mmHg and who were not receiving any
antihypertensive therapies were included in this study. Based
on the ABPM results, the prevalence of MHT was determined
to be 28.2% (MHT group, n ¼ 24). The ABPM averages of the
remaining 61 patients were within normal limits (normoten-
sive group). The duration of DM within the MHT group
was significantly shorter. In addition, the MHT group had
higher BMI and lower HDL-C levels. Demographic charac-
teristics and laboratory findings for the two groups are
summarized in Table 1.
Exercise duration (min) and exercise capacity (METs)
values were lower in the MHT group when compared to
the normotensive group [exercise duration: 8.0  1.9 versus
9.2  1.8 min (p ¼ 0.05), respectively; and exercise capacity:
 12 H. Akilli et al. Clin Exp Hypertens, 2014; 36(1): 9–16

Table 1. Demographics and laboratory findings of the patients.

Normotensive (n ¼ 61) MHT (n ¼ 24)

Parameters Mean  SD/Median (IQR) Mean  SD/Median (IQR) p Value
Age (years) 50.4  8.7 51.6  7.1 0.55
Gender (F/M) 25/36 10/14 0.91
Smoking n (%) 12 (19.6%) 5 (20.8 %) 0.64
BMI (kg/m2) 28.6  4.9 31.5  5.3 0.03
Waist–hip ratio 0.96  0.09 0.93  0.06 0.11
Duration of DM (year) 5.0 (8.0) 3.0 (5.0) 0.05
Medications n (%)
Insulin 32 (52%) 9 (38%) 0.24
OAD 48 (77%) 20 (83%) 0.54
ASA 21 (34%) 10 (42%) 0.38
Statins 17 (27%) 8 (33%) 0.59
Glucose (mg/dl) 163.5  66.8 156.7  51.4 0.65
HbA1c (%) 7.8  1.8 7.7  2.2 0.92
Creatinine (mg/dl) 0.75  0.17 0.68  0.12 0.09
Creatinine clearance (ml/min) 112.9  20.5 118.0  18.4 0.29
Total cholesterol (mg/dl) 204.8  37.9 190.4  35.8 0.11
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LDL-C (mg/dl) 124.0  29.1 117.4  31.9 0.36

HDL-C (mg/dl) 43.0  8.6 38.4  8.5 0.03
Triglyceride (mg/dl) 184 (145) 161 (113.8) 0.34
Hemoglobin (g/dl) 14.1  1.2 13.9  1.2 0.96

Bold values indicate significant p values.

MHT: Masked hypertension; IQR: Interquartile range; BMI: Body mass index; DM: Diabetes mellitus; OAD: Oral
antidiabetic; ASA: Acetyl salicylic acid; LDL-C: Low-density lipoprotein cholesterol; HDL-C: High-density
lipoprotein cholesterol.

and EBPR as independent predictors of MHT (Table 4). Cut-

off values for MHT were determined using ROC curves
For personal use only.

generated with the MedCalc software package as follows:

exercise capacity 9.0 METs [sensitivity: 50.1%, specificity:
88.5%, positive predictive value: 63.2%, negative predictive
value: 81.8% (Figure 4)], and exercise duration 8.08 minutes
[sensitivity: 50%, specificity: 82%, positive predictive value:
52.2%, negative predictive value: 80.6% (Figure 5)].

Figure 2. A comparison of exercise duration, exercise capacity and
EBPR. EBPR: Exaggerated blood pressure response to exercise.
9.1  1.8 versus 10.4  1.6 METs (p ¼ 0.02), respectively].
The frequency of EBPR was significantly greater in the MHT
group (25.0%) as compared to that of the normotensive group
(8.2%) (p ¼ 0.03) (Figure 2). DBP values were higher in the
MHT group than in the normotensive group during the pre-ETT
period, and during stages 1, 2 and 3. The two groups had similar
DBP values at peak exercise capacity and during the 3rd minute
of the recovery period. The pre-ETT and peak exercise SBP
values were higher in the MHT group (Figure 3). The ABPM
findings of the groups are displayed in Table 2.
Exercise duration and exercise capacity were negatively
correlated with age, HbA1c, mean daytime BP and mean
24 hour BP (Table 3). While univariate logistic regression
analysis revealed BMI as a predictor of MHT (OR: 1.17, CI
95%: 1.02–1.30, p ¼ 0.03), this finding was not observed with a
multivariate logistic regression analysis. Multivariate logistic
regression analysis identified DM duration, exercise capacity
Discussion
To our knowledge, the present study is the first to examine
the role of exercise capacity in identifying MHT in sedentary
DM subjects. A lower exercise capacity, shorter exercise
duration and an increased EBPR frequency were found in the
MHT group when compared to the normotensive group.
The present study also revealed that exercise capacity, EBPR
and duration of DM were independent predictors of MHT in
sedentary type 2 DM subjects.
While the prevalence of MHT is approximately 10% in the
general population (20), rates of 30–47% have been reported
among patients with DM, meaning that DM patients have a 3-
to 4-fold higher MHT incidence (1,21). In our study, the
incidence of MHT was 28.2%, a value consistent with the
literature. MHT has been reported to be associated with many
factors, such as age, male gender, smoking, alcohol con-
sumption, increased BMI, high-normal office BP, DM and
stress (6,22–26). In our study, both SBP and DBP were often
higher in the MHT group when compared to the normotensive
group, but the differences were not statistically significant.
Lifestyle and metabolic risk factors are also often associated
with MHT (27–29). In this study, patients with MHT had
higher BMI and lower HDL-C levels than those in the
normotensive group. Previous studies have demonstrated
an association between obesity and physical inactivity (30).
 DOI: 10.3109/10641963.2013.783047 Exercise capacity in predicting masked hypertension 13

Figure 3. A comparison of treadmill exercise results. (a) Systolic BP (mmHg), (b) Diastolic BP (mmHg), (c) Heart rate (beats/min). BP: Blood
pressure, *p50.05, **p50.01.

Table 2. Ambulatory BP characteristics. Table 4. The independent predictors of MHT in the multiple stepwise
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logistic regression model.

Blood
pressure Normotensive MHT Variables Beta Odds 95%CI of Odds p
Parameters (mmHg) (n ¼ 61) (n ¼ 24) p
First step
Office BP SBP 120.9  8.5 125.5  8.1 0.26 Age 0.01 1.01 0.93–1.10 0.80
DBP 77.2  5.7 80.1  7.1 0.38 Gender 0.37 0.69 0.15–3.15 0.63
Ambulatory BP BMI 0.04 0.96 0.80–1.16 0.69
Daily SBP 122.5  3.6 140.4  4.8 0.001 Duration of DM 0.22 0.80 0.65–0.98 0.03
DBP 73.0  6.3 83.7  4.5 0.001 HbA1c 0.12 1.13 0.79–1.61 0.50
Mean ABP 84.7  6.3 97.5  4.0 0.001 Total cholesterol 0.01 0.98 0.97–1.01 0.18
SBP 119.6  7.4 136.6  5.3 0.001 HDL-C 0.55 0.95 0.87–1.03 0.21
24 hours DBP 70.3  5.4 81.0  4.3 0.001 SBP at office 0.01 1.01 0.93–1.09 0.84
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Mean ABP 81.4  5.3 93.3  4.2 0.001 Exercise time 0.77 2.16 0.55–8.52 0.27
SBP 114.9  10.0 130.9  12.6 0.001 Exercise capacity 1.22 0.29 0.07–1.33 0.08
Night DBP 65.3  6.2 74.0  6.4 0.001 EBPR 2.12 8.30 1.40–15.86 0.02
Mean ABP 77.1  7.1 87.8  7.6 0.001 SBP at the peak exercise 0.001 1.00 0.98–1.03 0.98
Early morning SBP 123.0  8.5 128.6  7.5 0.11 The last step
DBP 75.3  9.0 75.4  9.9 0.97 Duration of DM 0.23 0.84 0.71–0.96 0.03
Systolic dipping (%) 6.3  7.0 6.7  8.2 0.68 Exercise capacity 0.49 0.61 0.39–0.95 0.03
Diastolic dipping (%) 10.3  8.1 11.9  7.0 0.79 EBPR 2.20 9.45 1.72–16.90 0.01

Bold values indicate significant p values. Bold values indicate significant p values.
MHT: Masked hypertension; BP: Blood pressure; SBP: Systolic blood BMI: Body mass index; DM: Diabetes mellitus; HDL-C: High-density
pressure; DBP: Diastolic blood pressure; ABP: Ambulatory blood lipoprotein cholesterol; SBP: Systolic blood pressure; EBPR:
pressure Exaggerated blood pressure response to exercise.

Table 3. The linear relationships of among exercise capacity, exercise

duration, BP measurements and other clinic factors.

Exercise Exercise
Time Capacity
(n ¼ 85) (n ¼ 85)
ra,b p r p
a a
Age 0.30 0.01 0.30 0.01
BMI 0.10a 0.39 0.08a 0.45
Duration of DM 0.04b 0.72 0.03b 0.81
24 hour SBP 0.25a 0.03 0.24a 0.04
24 hour DBP 0.12a 0.33 0.13a 0.27
24 hour mean BP 0.23a 0.04 0.24a 0.04
Daytime SBP 0.19a 0.10 0.20a 0.06
Daytime DBP 0.48a 0.66 0.83a 0.46
Daytime mean BP 0.22a 0.04 0.23a 0.04
Systolic dipping 0.24a 0.04 0.19a 0.10
Diastolic Dipping 0.19a 0.10 0.15a 0.19
Total cholesterol 0.09a 0.42 0.06a 0.59
HDL-C 0.10a 0.36 0.04a 0.72
LDL-C 0.13a 0.25 0.08a 0.47
Triglyceride 0.16b 0.15 0.14b 0.20
HbA1c 0.32a 0.003 0.27a 0.01

Bold values indicate significant p values.

SBP: Systolic blood pressure; DBP: Diastolic blood pressure; BP: Blood Figure 4. Receiver operating curve of exercise capacity for the masked
pressure; HR: Heart rate; ra: Pearson correlation coefficient; rb: hypertension.
Spearman correlation coefficient; p: Level of statistical significance.
 14 H. Akilli et al.
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Figure 5. Receiver operating curve of exercise duration for the masked
hypertension.
Although the mechanism behind physical inactivity in obesity
remains unclear, multifactorial etiology has been advocated
(31,32). In our study, univariate logistic regression analysis
revealed BMI as a predictor of MHT; however, multivariate
logistic regression analysis could not demonstrate such
an association. In addition, there was no linear relationship
For personal use only.
between exercise capacity and BMI. This finding supports the
idea that the association between reduced exercise capacity
and obesity is multifactorial. Obesity may contribute to
reduce exercise capacity in the MHT group. On the other
hand, an important predisposing factor of obesity has a
sedentary lifestyle and physical inactivity in this group.
Hence, there is a need forcomprehensive studies in this area.
Interestingly, the duration of DM for patients with MHT
was about 2.5 years shorter than that of the normotensive
patients. Regression analysis identified the duration of DM as
an independent predictor of MHT. Previous studies have
revealed that at 6-year follow-up, 35% of patients with MHT
had developed sustained HT (33). Patients with a long DM
duration might have been excluded from the study due to the
types of drugs they were required to use, such as angiotensin-
converting enzyme inhibitors/angiotensin-receptor blockers
and especially those used to protect against the risk of
nephropathy. Therefore, we hypothesize that the duration
of DM is shorter in the MHT group.
ETT is commonly used in clinical practice to predict MHT.
Although there are studies reporting the use of ETT to predict
MHT in the general population, there are very limited data
in the DM population (11,12,14,34). However, MHT is more
common among patients with DM. In a study of 61 patients
with type 2 DM, Kramer et al. determined that peak SBP and
DBP values were higher among MHT patients during the ETT
(14). Similarly, in our study, peak SBP values were higher in
the MHT group while both groups had similar DBP values.
Kramer et al. found that the MHT and normotensive groups
had similar exercise capacities, although exercise periods
were not specified in the publication. The largest drawback of
the study by Kramer et al. was that the patients’ daily physical
activity levels were not rated. The mean BMI of patients with
Clin Exp Hypertens, 2014; 36(1): 9–16
MHT in the study by Kramer et al. was 27.8, while in our
study, the mean BMI was 31.5 and largely depended on
patient activity levels. Exercise capacity may be associated
with activity level, and therefore the inconsistent results
regarding exercise capacity may be explained by the propor-
tion of sedentary patients in the sample group. EBPR is the
ETT parameter that is the most hotly debated in the literature
and is most associated with HT. It has been reported that
EBPR increases the future risk of HT 3.8 times in the general
population (35). Furthermore, 41% of patients with EBPR
also have MHT (11). We did not find any studies that reported
a relationship between EBPR and MHT for patients with DM.
In our study, the relationship between EBPR and MHT was
evaluated among sedentary type 2 DM patients, and the
development of EBPR during the ETT was associated with a
9.4-fold increased risk of MHT.
In our study, exercise duration and exercise capacity
values were significantly lower in the MHT group than in the
normotensive group, and exercise capacity was an independ-
ent predictor of MHT. Previous studies have demonstrated
that low exercise capacity is associated with cardiovascular
events and mortality in the general population (36) as well as
in DM patients (37,38). MHT has been similarly associated
with increased mortality and adverse cardiovascular events
(4,39). However, the effect of MHT on exercise capacity is
unknown for patients with DM. Our study shows that the
incidence of MHT is 57.9% among patients with exercise
capacities 59.0 METs and is 19.7% for those with exercise
capacities 9.0 METs. Previous studies have shown that
MHT can cause left ventricular hypertrophy (LVH) in patients
with DM (3,22). A relationship between LVH and low
exercise capacity has also been previously shown (40). We
could not find any data regarding the relationship between
low exercise capacity and MHT in the current literature.
Many studies have shown impaired diastolic function in
DM patients (41,42). In the light of the current literature,
we hypothesize that MHT increases the left ventricular (LV)
mass in DM patients, and diastolic dysfunction may be
worsened during exercise, resulting in reduced exercise
capacity.
Limitations of the study
A major limitation of this study was the small number of
patients. However, our study is among those with the largest
patient sample size in the current literature and investigates
the relationship between ETT and MHT. Our study sample
included both sexes. Because of the relatively small number
of subjects in the MHT group, a subgroup analysis according
to gender was not performed. However, a regression model
showed that reduced exercise capacity may predict MHT
independently from gender. The power of the study appears to
be sufficient. However, to generalize the results to all DM
patients, larger sample studies are needed. It is not reasonable
to generalize our results to all DM patients since our study
was limited to sedentary individuals. Because of potential
false negative results from the ETT, the effects of silent
myocardial ischemia on the study results remain unclear.
LV mass values and diastolic function, determined using
echocardiography in diabetic cardiomyopathy patients, were
 DOI: 10.3109/10641963.2013.783047
not investigated. Adding echocardiographic data might have
improved the quality of the study, but these data were not
included due to the cost.
Conclusion
Exercise capacity measured by an ETT was decreased in
patients with MHT and in sedentary diabetics. In addition to
EBPR, assessment of exercise capacity may provide clues
to predicting MHT in sedentary type 2 DM patients. Because
of the increased prevalence of MHT in patients with DM and
the limited availability of ABPM devices in clinical practice,
exercise capacity and EBPR may be a reasonable guide for the
selection of DM patients who are eligible for ABPM records.
Furthermore, when ETT becomes a routine and commonly
used test in the detection of ischemic heart diseases in type 2
DM patients, our findings may be useful and directive for
Clin Exp Hypertens Downloaded from informahealthcare.com by Universitaet Zuerich on 12/28/14
clinical practice.
Acknowledgements
The authors thank the staff of the ETT unit for their kind
cooperation.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
This study was financially supported by the Scientific
For personal use only.
Investigation and Project Foundation of Selcuk University
(Project number: 09102016).
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