Peripheral Arterial Responses to Treadmill Exercise Among
Healthy Subjects and Atherosclerotic Patients
Alan Rozanski, MD; Ehtasham Qureshi, MD; Mara Bauman, MA; George Reed, PhD;
Giora Pillar, MD; George A. Diamond, MD
Background—Peripheral cutaneous vascular beds, such as the fingertips, contain a high concentration of arteriovenous
anastomoses, richly innervated by a-adrenergic nerve fibers, to control heat regulation. Nevertheless, for a variety of
technical reasons, finger blood flow responses to exercise have not been well studied in health and disease. Hence, we
compared finger pulse-wave amplitude (PWA) responses to exercise among 50 normal volunteers and 57 patients with
atherosclerotic coronary artery disease (CAD) using a robust, modified form of volume plethysmography.
Methods and Results—PWA was quantified for each minute of exercise as a ratio relative to baseline. Exercise PWA
responses were compared with clinical, hemodynamic, ECG, and myocardial single photon emission computed
tomography parameters. Among normal subjects, 38 (76%) manifested vasodilation throughout exercise and 12 (24%)
manifested initial vasodilation followed by vasoconstriction at high heart rate thresholds. None manifested vasoconstriction throughout exercise. By contrast, 20 CAD patients (35%) manifested progressive vasoconstriction from the
onset of exercise, and 10 others (18%) manifested vasoconstriction at low heart rate thresholds (P,0.001 versus
normals) after initial vasodilation with exercise. Patients exhibiting vasodilation versus vasoconstriction during exercise
had similar clinical and exercise profiles, except for a greater use of ACE inhibitors and a greater level of achieved
metabolic equivalents among the former (P,0.05 for both).
Conclusions—Half of our CAD patients manifested diminution in PWA that was consistent with peripheral arterial
vasoconstriction during the early phases of treadmill exercise. Such paradoxical vasoconstrictive responses were not
observed in normal subjects and, therefore, they may represent generalized vascular pathology secondary to
atherosclerosis. (Circulation. 2001;103:2084-2089.)
Key Words: exercise n coronary disease n blood flow n body temperature regulation
C
variety of technical reasons, however, finger plethysmography has found limited application in exercise stress testing.
The potential interest in studying peripheral cutaneous
blood flow responses to exercise lies in the unique physiology
governing this stressor. Because core body temperature increases during exercise, the central nervous system selectively decreases its tonicity to the peripheral cutaneous
vascular beds, thereby promoting peripheral vasodilation and
consequent heat loss.8 Thus, the increase in finger pulsatile
blood volume is the expected physiological response to
exercise, but it is not known if—and how—this response
varies among healthy subjects and atherosclerotic patients.
Accordingly, we evaluated peripheral thermoregulatory responses by means of a new plethysmographic device that is
applicable for exercise use. The goals of the study were to
compare exercise thermoregulatory responses among normal
utaneous vascular beds in peripheral regions (such as the
fingers and toes) and nonperipheral regions (such as the
limbs and body trunk) together govern thermoregulation. The
peripheral cutaneous regions, however, are characterized by a
unique anatomic structure, including a large number of
arteriovenous anastomoses that are densely innervated by
a-adrenergic fibers,1 no significant muscle mass, and lack of
b-receptors.2 As a consequence, these cutaneous regions may
afford a unique window into assessing the activation of the
sympathetic nervous system. Such activation is characteristically manifested by profound diminution in finger blood flow
during physiological stimuli as varied as cold stimulation and
mental stress,3–5 the arousal state from sleep apnea,6 and
REM sleep.7 Because the finger is particularly accessible for
measurement, finger plethysmography is a convenient
method for assessing such physiological phenomena. For a
Received December 8, 2000; revision received January 24, 2001; accepted January 26, 2001.
From the Department of Medicine, St Luke’s/Roosevelt Hospital, New York, NY (A.R., E.Q., M.B., G.A.D.); the Division of Preventive and Behavior
Medicine, University of Massachusetts Medical School, Worcester, Mass (G.R); and the Department of Medicine, Brigham and Women’s Hospital,
Boston, Mass (G.P.).
Drs Rozanski and Diamond serve as consultants to Itamar-Medical, which makes the plethysmographic device used in the study.
Presented in part at the 73rd Annual Scientific Sessions of the American Heart Association, New Orleans, La, November 12–15, 2000, and published
in abstract form (Circulation. 2000;102:II-522).
Correspondence to Alan Rozanski, MD, Division of Cardiology, St Luke’s/Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY 10025.
E-mail AR77@columbia.edu
© 2001 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
2084
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Rozanski et al
Exercise Finger Pulse Volume Responses
2085
Figure 2. Raw pulse-wave tracing in a representative subject
before, during, and immediately after treadmill exercise. Leftmost portion of graph was recorded at a fast paper speed
(25 mm/s) to allow recognition of waveform; remainder of tracing was recorded at a slow speed (1 mm/s) to show temporal
trend of PWA over time. Shaded region of interest identifies
period of exercise.
Figure 1. Schematic diagram illustrating sensor’s structure and
function. Sensor is partitioned into 2 contiguous sections of
equal length, each consisting of an external rigid case that is
bound to an internal latex membrane in an airtight manner. Air
tubes connect each segment to a console that controls pressure. Sensor cap is thimble-shaped and longitudinally split so
that when pressurized, it imparts a 2-point clamping effect to
lock sensor firmly to fingertip. This part of the sensor is used to
measure pulsatile volume changes in distal finger phalanx. Volume changes that accompany pulse-waves alter pressure in
space surrounding fingertip, which is sensed by a pressure
transducer within console. An open-ended annular cuff contiguous to sensor tip and pressurized to same level provides a buffering effect against blood volume perturbations. This compartment also extends the effective boundary of sensing
compartment. Cuff section is not used for sensing pulsatile volume changes. Both compartments are pressurized to an equal
level, which is designed to prevent venous transmural pressure
from becoming positive, even if finger is maximally lowered,
thereby preventing venous pooling from occurring.
volunteers and patients with atherosclerotic coronary artery
disease (CAD) and to characterize the clinical and hemodynamic mediators of these responses.
Methods
Study Population
Fifty apparently healthy volunteers, without known illnesses, were
recruited to assess the effects of exercise on finger blood flow. The
mean age of this “normal” group was 33611 years (range, 19 to 62
years), and 30 (60%) were men. A total of 57 patients with clinically
significant coronary atherosclerosis, as determined by prior angiography ($50% stenosis) and/or history of prior myocardial infarction,
were also selected from among patients undergoing exercise myocardial perfusion single photon emission computed tomography
(SPECT) on a clinical basis; 38 had prior myocardial infarction, and
43 had undergone a prior coronary revascularization procedure. The
mean age of this patient population was 62610 years (range, 40 to
83 years), and 48 (82%) were men. All subjects gave informed
consent.
Assessment of Finger Pulse Volume Responses to
Physiological Stimulation
Pulsatile blood volume responses were assessed by peripheral
arterial tonometry using a plethysmographic device (ItamarMedical) designed to reflect only pulsatile arterial volume changes.
As shown in Figure 1, the principal features of this device include a
buffering proximal probe component and the application of a
constant counterpressure of 70 mm Hg within the entire probe to
keep venous transmural pressure deliberately negative. These features thereby prevent venous pooling and stasis within the instrumented part of the finger and inhibit blood volume pertubation. The
counterpressure also serves, in part, to unload arterial wall tension,
thus improving the dynamic range of the arterial pulse excursions.
Another device feature, the splitting of its distal cap, prevents the
probe from generating a net force vector that would tend to push it
away from the finger during its use. The probe components are
connected by thin flexible tubing to isolated volume reservoirs to
buffer pressure changes within the probe. A further volume reservoir
that is not connected to the probe serves as a pressure reference. The
pressure changes accompanying peripheral volume changes are fed
to a personal computer, by which the signal is band pass-filtered (0.3
to 30 Hz), amplified, displayed, and stored.
Exercise Protocol
Patients were instructed to be off nitrates for 6 hours, calcium
channel blockers for 24 hours, and b-blockers for at least 48 hours
before testing. The Bruce exercise protocol9a was performed in a
thermoneutral environment (21°C). Patients exercised to exhaustion,
unless severe chest pain or hypotension intervened. Finger pulsewave measurements were obtained continuously. Subjects were
requested to lean the forearm of the monitored hand lightly on a
padded supporting device attached to the treadmill’s side rail to
minimize free hand movement.
Assessment of Pulse-Wave Amplitudes
Nonperiodic data related to incidental patient motion were removed
from the pulse-wave tracings by electronic filtering. A region-ofinterest was then defined between the beginning and end of exercise
(Figure 2). Baseline amplitude was determined by averaging over the
first 2 minutes of exercise. Average amplitude was then determined
for each subsequent minute of exercise and expressed as a ratio
compared with the baseline amplitude.9b
Gated Myocardial Perfusion Imaging
Gated SPECT imaging was performed using conventional methodology. Data were acquired after the injection of Tc-99m sestamibi (9
to 10 mCi at rest; 30 to 31 mCi at peak exercise) in 64 projections
over a circular 180° orbit, with the scintillation camera set at a 140
keV energy peak with a 20% window, using a high resolution
collimator and 2D Butterworth filter. Transaxial tomograms were
reconstructed using back projection with a ramp filter. Resting left
ventricular ejection fraction and volumes were calculated using a
semiautomated volumetric algorithm.9b
Assessment of Exercise Test Results
The exercise ECG response was considered ischemic if horizontal or
downsloping ST-segment depression $1 mm or upsloping STsegment depression $1.5 mm occurred from the baseline ECG,
when measured 0.08 s after the J point. Rest and exercise myocardial
scintigrams were assessed semiquantitatively for each of 20 standardized myocardial segments in the apical, midventricular, and
basal left ventricular regions. The presence of reversible hypoperfusion defined a scan as ischemic.
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April 24, 2001
Results
Baseline Exercise Responses
Exercise duration averaged 9.661.9 minutes for volunteers,
none of whom developed evidence of ischemia. Exercise
duration averaged 8.262.5 minutes for the atherosclerotic
patients (P,0.002 versus volunteers); 16 (28%) developed an
ischemic response to exercise (2 abnormal clinical responses,
12 abnormal electrocardiographic responses, and 8 abnormal
SPECT responses).
Exercise Pulse-Wave Amplitude Responses
Figure 3. Characteristic patterns of PWA response to treadmill
exercise (from top to bottom): a progressive increase in amplitude during exercise; a relatively flat amplitude response during
exercise; a progressive decrease in amplitude during exercise;
and a transition from an early increase to a late decrease in
amplitude during exercise.
Statistical Analysis
All analyses used the summary minute-by-minute amplitude data.
The amplitudes during exercise were expressed as a ratio relative to
baseline amplitude; ratios .1 represented “vasodilation,” ratios 51
represented “no change,” and ratios ,1 represented “vasoconstriction.” “Maximal” pulse wave amplitude was the maximum of all
averaged minute-by-minute points during exercise. “End-exercise”
amplitude ratio was that computed for the last minute of exercise.
Clinical, hemodynamic, exercise ECG, and exercise SPECT results
within CAD subgroups, divided by their peripheral blood flow
responses to exercise, were compared using a Fisher’s exact test for
categorical variables and a t test for continuous measurements.
By visual analysis, the temporal change in pulse-wave amplitude (PWA) with exercise ranged from progressive increases to progressive decreases, with some subjects showing
a mixed pattern of an initially maintained or increased finger
PWA during early exercise, followed by diminution in PWA
later during exercise (Figure 3). The maximal PWA ratio
during exercise (expressed as a percent relative to baseline)
was significantly higher in the volunteers than in the patients
(165642% versus 118642%, P,0.001), and the slope of
PWA change during exercise was significantly more positive
in the volunteers than in the patients (1.0560.96 min–1 versus
0.0361.58 min–1, P,0.001).
Individual PWA responses for the volunteers and patients
are illustrated in Figure 4. Two basic temporal PWA patterns
were observed in the volunteers: 38 (76%) manifested a rise
in PWA during the course of exercise, and 12 (24%) had a fall
in PWA below the baseline value at or before the end of
exercise after an initial rise. Eleven volunteers (22%) manifested a transient diminution of PWA below the baseline at
the very onset of exercise, before the characteristic rise began.
Figure 4. Individual PWA responses to exercise (expressed as a percent relative to baseline) among healthy volunteers (top) and
patients with documented coronary atherosclerosis (bottom). Definition of each pattern is summarized along top of figure. Left panels
represent PWA responses that tended to increase during exercise; middle panels represent PWA responses that peaked and then
declined before peak exercise; and right panels represent PWA responses that declined throughout exercise. Top right panel is blank
because such responses were not observed in volunteers.
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Rozanski et al
2087
Exercise Finger Pulse Volume Responses
Comparison of Clinical and Hemodynamic Variables
Parameters
Exercise Finger
Vasodilators
(n537)
Exercise Finger
Vasoconstrictors
(n520)
Clinical history
Age, y
Figure 5. Frequency of PWA patterns falling below 100% baseline as a function of magnitude of exercise stress (quantified in
terms of percent maximal predicted heart rate). In patients, frequency of amplitudes falling below 100% increased progressively with increasing stress. In contrast, frequency of amplitudes falling below 100% in volunteers remained very low until
at least 90% of maximal predicted heart rate was achieved.
Three temporal patterns of PWA were observed among the
atherosclerotic patients: 27 (47%) manifested a rise in PWA
during exercise, 10 (18%) exhibited an initial rise followed by
a fall before the end of exercise, and 20 (35%) manifested a
fall in amplitude from the onset of exercise that worsened
progressively during exercise. For the volunteers and patients
who manifested an initial rise followed by a fall in amplitude,
the onset of the transition occurred at significantly lower
thresholds among the patients than in the controls (120611
bpm versus 162621 bpm, P,0.01; 77611% versus 88612%
of maximal predicted heart rate, P,0.01; and 5.261.5 versus
7.462.3 minutes, P,0.05). Among the patients, the frequency of PWA falling below the initial baseline value
increased progressively with increasing percent of maximal
predicted heart rate; by contrast, amplitudes below the baseline value were uncommon in volunteers at ,90% of maximal predicted heart rate (Figure 5).
62.2611.1
60.667.2
Men
32 (86)
16 (80)
Anginal chest pain
11 (30)
8 (40)
MI
27 (73)
11 (55)
PTCA
21 (57)
15 (75)
CABG
7 (19)
6 (30)
21 (57)
11 (55)
Hypertension
Diabetes
6 (16)
5 (20)
26 (70)
14 (70)
2 (5)
2 (10)
BMI, kg/m2
26.963.9
27.365.2
Rest HR, beats/min
68.7613.6
71.9611.4
Rest SBP, mm Hg
132.4615.6
133.5618.1
History of increased cholesterol
Currently smoking
Resting parameters
Rest DBP, mm Hg
84.8610.2
85.0610.5
Rest MAP, mm Hg
100.7610.5
101.2611.7
EDV, cc
104.0663.2
94.2662.6
LVEF, %
59.8611.8
59.2619.5
Medication use
Statins
17 (46)
8 (40)
ACE inhibitor
11 (30)
1 (5)*
Calcium blockers
10 (27)
3 (15)
b-Blockers
17 (46)
9 (45)
8.662.7
7.662.9
10.562.6
8.763.0*
Exercise parameters
Exercise time, min
Peak METs
Evaluation of Predictors
Peak HR, beats/min
146.3614.3
144.0611.7
To identify potential clinical predictors of finger blood flow
responses to exercise, we compared a number of clinical
parameters among the CAD patients, who were divided into
2 groups: the 20 patients who manifested PWA exercise
responses consistent with initial and progressive vasoconstriction were 1 group, and the 37 patients who manifested
responses consistent with initial vasodilation were the other.
As shown in the Table, there was a significant difference
between these 2 groups with respect to the use of ACE
inhibitors and the achieved level of metabolic equivalents,
each of which was greater among the patients manifesting
vasodilation.
Peak SBP, mm Hg
169.5621.1
172.5637.4
Peak DBP, mm Hg
89.1610.9
89.868.5
Peak MAP, mm Hg
115.9612.4
117.4612.8
Ischemic ECG
5 (13)
7 (35)
Exercise chest pain
1 (3)
1 (5)
Ischemic SPECT
5 (14)
3 (15)
Values are means6SD or n (%). MI indicates myocardial infarction; PTCA,
percutaneous transluminal coronary angioplasty; CABG, coronary artery bypass
grafting, BMI, body mass index; HR, heart rate; SBP, systolic blood pressure;
DBP, diastolic blood pressure; MAP, mean arterial blood pressure; EDV,
end-diastolic volume; LVEF, left ventricular ejection fraction; and MET, metabolic equivalent.
*P50.05.
Discussion
Our results indicate significant differences in the peripheral
vasodilator responses to exercise among healthy normal
volunteers and patients with proven atherosclerotic CAD.
Finger PWA rose progressively throughout exercise in the
volunteers, but in '25% of such subjects, there was a late
reversal, with declines in PWA beginning at a mean heart rate
of 162621 bpm. In contrast, .33% of the CAD patients
manifested a fall in PWA from the onset of exercise. These
falls, which were not observed among normal volunteers,
were characteristically progressive in nature and worsened
throughout the exercise period. Other CAD patients manifested falls in finger PWA that began at substantially lower
heart rate thresholds compared with the late falls observed in
some of the volunteers. Consequently, the finger pulse wave
responses to exercise among the CAD patients were quite
heterogenous. Clinical and exercise parameters did not differ
among the CAD patients manifesting vasoconstrictor and
vasodilator responders, except for a greater use of ACE
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Circulation
April 24, 2001
inhibitors and higher achieved peak metabolic equivalents
among the vasodilators.
Potential Explanations
Because peripheral cutaneous vascular regions, such as the
fingers and toes, are densely innervated by a-adrenergic
nerve fibers, local vasoconstrictive responses are characteristically elicited during activation of the sympathetic nervous
system.1,3–7 Exercise, however, is a unique stimulus in that
heat stress causes central-mediated withdrawal of vasoconstrictor outflow to peripheral vascular beds. Accordingly, the
peripheral arteriovenous plexuses increase in size and come
closer to the skin surface, thus facilitating heat loss. Of note,
a-adrenergic stimulation is still present during exercise, so
the peripheral vascular regions are under the influence of
competitive stresses during exercise: heat stress (favoring
peripheral vasodilation) and a-adrenergic stimulation (favoring peripheral vasoconstriction).8 Thus, it can be reasoned
that any condition that alters this competitive balance in favor
of a-adrenergic stimulation might favor the elicitation of a
paradoxical decrease in cutaneous finger blood flow with
exercise. One condition previously shown to alter this competitive balance in favor of peripheral vasoconstriction during
exercise is diminished cardiac output, as seen in patients with
heart failure.10 However, because few patients in our study
had abnormal left ventricular function at rest or the induction
of myocardial ischemia during exercise, other factors must
also be operative in mediating abnormal peripheral vascular
responses to exercise. The potential role of nitric oxide–
mediated vasodilation within peripheral arteries11 is of particular interest in this regard, because many CAD patients
manifest concomitant peripheral endothelial dysfunction.12 It
was previously demonstrated that the effects of circulating
catecholamines are enhanced in the presence of peripheral
endothelial dysfunction,13,14 but it is presently unknown
whether nitric oxide helps facilitate the vasodilatory effects of
heat stress or retard the vasoconstrictive effects of sympathetic stimulation at the level of cutaneous finger arterioles.
The higher use of ACE inhibitors among CAD patients
manifesting finger vasodilation is consistent with this possibility given their amelioration of endothelial dysfunction,15
but many finger vasodilators were also not on ACE inhibitor
therapy. Alternatively, consideration could focus on whether
central-mediated processes contributed to our findings.
Peripheral PWA and Blood Pressure Changes
Decreases in finger PWA during exercise were not associated
with differences in brachial arterial blood pressure responses
to exercise, suggesting a dissociation between peripheral
finger blood flow responses and more central blood pressure
changes. Of note in this regard, a different physiology
governs the vascular responses within the forearm and other
proximal vascular regions because of the presence of significant muscle mass, b-receptors, and an active cutaneous
vasodilator system within these regions, which is not found in
cutaneous peripheral regions.16,17 By contrast, the arteriovenous anastomoses found in the finger region are absent in
these more proximal vascular beds. That these arteriovenous
anastomoses govern a unique vascular response is evidenced
by findings demonstrating that the progressive increase in
arteriovenous anastomoses from hand to proximal finger
phalanxes and then distal finger phalanx are accompanied by
a progressive increase in the magnitude of vasoconstriction to
physiological stimuli as well.5 Consequently, forearm blood
flow shows little vascular response to stimuli that produce
profound vasoconstriction in the fingers.5
Peripheral pulse-wave responses to exercise were not
further compared with peripheral arterial blood pressure
responses at the finger level in our study, but it has been
demonstrated that peripheral arterial blood pressure at the
finger level is maintained during exercise among CAD
patients.18 Doupe et al19 demonstrated that transient reductions in finger blood flow can occur without causing a
reduction in peripheral blood pressure in nonexercise settings.
Other studies have found that transient decreases in peripheral PWA during anesthesia are not associated with significant effects on peripheral arterial blood pressure, when
measured simultaneously.20,21 Given that pulse pressure usually increases substantially during exercise, thus inducing an
increase in the finger pulse waveform, a selective, sympathetically mediated decrease in regional vascular compliance
represents the most likely explanation for those patients
manifesting reductions in finger PWA during exercise in our
study.
Implications for Exercise Efficiency
Zelis et al10 previously postulated that sympathetically mediated cutaneous vasoconstriction during exercise inhibits heat
loss among patients with congestive heart failure, perhaps
explaining the heat intolerance observed in such patients. Our
observations further raise the issue of whether CAD patients
manifesting peripheral vasoconstriction in the absence of left
ventricular dysfunction are also subject to impaired heat loss.
Second, given that the achieved metabolic equivalent level
was lower among CAD patients manifesting peripheral vasoconstriction, prospective study may be indicated to determine
whether such peripheral vasoconstrictors are subject to diminished exercise efficiency.
Limitations
Peripheral arterial tonometry measures pulsatile changes in
volume rather than flow. Although previous studies have
demonstrated a correspondence between these 2 measures,1,22
caution should be exerted in substituting one as a measure for
the other.22 Although the assessment of PWA by peripheral
arterial tonometry is relatively free of artifacts when individuals are monitored at rest, the recordings are subject to
technical artifact if there is undue patient motion during
exercise. These technical artifacts can be readily identified,
however, because they generally do not resemble characteristic pulse-waves. Various factors that may have affected
finger blood flow responses to exercise were not evaluated in
this study, such as the role of baroreflex and chemoreflex
function or the presence of autonomic nervous system dysfunction, which may be assessed, in part, by measuring
beat-to-beat variations of finger PWA in the frequency
domain.23 In addition, our findings were evaluated in a
limited sample of CAD patients, including mostly nonische-
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Rozanski et al
mic patients and those with normal resting left ventricular
function. Thus, an evaluation of sicker CAD cohorts would
seem to be indicated. In addition, evaluating other factors,
such as age, hypertension, and diabetes mellitus, would also
be of interest.
Conclusions
Using a newly modified volume plethysmographic device, we
discovered that a substantial percentage of CAD patients
manifest a progressive diminution in finger blood PWA
during exercise. Because normal individuals maintain or
increase finger PWA with exercise, these paradoxically
vasoconstrictive responses may reflect generalized peripheral
vascular pathology secondary to atherosclerosis.
Acknowledgment
Supported in part by a grant from Itamar-Medical, Caesaria, Israel.
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Peripheral Arterial Responses to Treadmill Exercise Among Healthy Subjects and Atherosclerotic
Patients
Alan Rozanski, Ehtasham Qureshi, Mara Bauman, George Reed, Giora Pillar and George A. Diamond
Circulation. 2001;103:2084-2089
doi: 10.1161/01.CIR.103.16.2084
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