Monitoring Beta-Blocker Therapy in Adolescents with Exercise-Induced Intraventricular Gradients Using Exercise Stress...

Background: Treadmill exercise stress echocardiography (ESE) is both feasible and safe in the pediatric population. Although regional wall motion abnormalities (RWMAs) have limited diagnostic utility, Doppler studies frequently demonstrate significant intraventricular pressure gradients (IVPGs) during exercise. These IVPGs, which were observed in 39% of 258 previously studied adolescents, are absent at rest. Their detection provides valuable insight into exercise-related symptoms and abnormal findings on resting or stress electrocardiograms (ECGs). Purpose: To evaluate the effect of β-blocker therapy on the occurrence of intraventricular pressure gradients (IVPGs) in adolescents presenting with symptoms or abnormal findings on resting or stress electrocardiograms (ECGs). Methods: Exercise stress echocardiography (ESE) was repeated in 66 of 101 adolescents who were found to have developed intraventricular pressure gradients (IVPGs) during the initial assessment. All participants had normal resting echocardiograms, and all underwent follow-up evaluation while receiving β-blocker therapy. The study cohort included 15 females (23%) and the mean age of participants was 14.6 ± 1.7 years (range: 11-17 years). Comprehensive two-dimensional and Doppler echocardiographic assessments were performed at baseline and during β-blocker treatment. Results: During the initial ESE, the mean intraventricular pressure gradient (IVPG) was 105 ± 38 mmHg. Under β-blocker therapy, 37 adolescents no longer developed IVPGs while, in the remaining 29 adolescents, the IVPG was significantly reduced to a mean of 58 ± 32 mmHg (p < 0.0001). The mean heart rate at peak exercise decreased from 178 ± 15 bpm at baseline to 157 ± 9 bpm during the repeat ESE under β-blocker treatment (p < 0.0001). Clinical symptoms were reproduced in forty-seven adolescents during the initial ESE, but occurred in only seven adolescents during treatment (p < 0.0001). Conclusions: In adolescents presenting with symptoms or abnormal resting or stress ECG findings, and exertional intraventricular pressure gradients (IVPGs), oral β-blocker therapy either prevented the occurrence of IVPGs or significantly reduced their severity. These hemodynamic improvements were associated with the resolution of clinical symptoms in 85% of the symptomatic cohort.