Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group

Hancheol Lee; Hyeongsoo Kim; Seungjin Oh; Jong-Kwan Park; Ji-Yong Jang; Kyeong-Hyeon Chun; Se-Jung Yoon

doi:10.1371/journal.pone.0285961

Peer Review History

Original SubmissionMay 12, 2023
2 Aug 2023 Decision Letter - Damon Leo Swift, Editor PONE-D-23-13242Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy groupPLOS ONE Dear Dr. Yoon, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 16 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: - 10.1097/MD.0000000000000428 - https://doi.org/10.3109/08037051.2012.759694 - https://doi.org/10.1016/j.ahj.2003.08.009 In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. 3. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. 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If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. 6. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. Additional Editor Comments: Please edit the present manuscript based on the reviewers comments. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: No ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The paper is solid , but the authors could make a stronger case for its importance , as if one is doing a stress test , one already has HRR so why is BP recovery needed . Likewise , why does one need to predict PP when it is so easy to measure by just taking BP? Reviewer #2: Dear authors, congratulations for your work about Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group. Your aim is not well defined in the manuscript, it is hard for the reader to understand your goal. You must define with more specification your aim and strenght the need for this study in the literature. "Why is important to do this study?" Suggestions: 1. Abstract: add sentence with background; Results: rewrite this part and remove statistical procedures; 2: Introduction: Add more setences about your topic and exercise type and population; Define with more specificity your study aim; 3: Methods: Add yoiur study design; Add exclusion criteria; Why not perform anova?; Add procedures 4: Results: redone statistical procedures; 5: Discussion: You need to add more specific literature to debate your results. E.g.:"The increase in heart rate during exercise was proportional to HRR in this group. It can be interpreted that HRR will be good if the HR increases sufficiently much during exercise." what is sufficiently much during exercise? ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Luis Leitão ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0285961.r001
Revision 1
18 Aug 2023 Author Response Rebuttal letter We appreciate you for all your kind and high-quality advice and respected and referred to the opinions of editors and reviewers as much as possible. We modified and reviewed them (below). All revised parts were highlighted and marked on the manuscript. Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf -We added the funding information to the revised manuscript as you recommended. -We modified the manuscript as below according to PLOS ONE's style requirements (TITLE, AUTHOR, AFFILIATIONS FORMATTING GUIDELINES & MANUSCRIPT BODY FORMATTING GUIDELINES). 1) We removed titles attached to the author's name (Do not include titles (Dr., PhD, M.D,,) 2) We listed corresponding author’s initials in parentheses after the email address. 3) We removed physical addresses of corresponding author but only mentioned email addresses. 4) We did not include ZIP or Postal Codes, street addresses, or building/office numbers of corresponding author as PLOS ONE's style requirements (Formatting Guidelines) 5) We modified all level 1 headings to be bold and 18pt font and level 2 headings to be bold and 16pt font each. 6) References ; The authors' names were limited to the first six authors, followed by ‘et al.’. 2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: - 10.1097/MD.0000000000000428 - https://doi.org/10.3109/08037051.2012.759694 - https://doi.org/10.1016/j.ahj.2003.08.009 In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. -The overlapping text you mentioned mainly corresponds to references 23 and 27, so we found these parts in the text and changed them to different expressions as much as possible (highlighted in the text). 3. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. -We specified the grant numbers for the award we have received for this study in the ‘Funding Information’ section and also added this point to the ‘cover letter’. 4. Thank you for stating the following financial disclosure: "no conflict of interest to declare." At this time, please address the following queries: a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” c) If any authors received a salary from any of your funders, please state which authors and which funders. d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. -We listed the source of funding and the grant numbers in the manuscript and we clearly state that the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript in cover letter. 5. Thank you for stating the following in your Competing Interests section: "There is no conflict of interest." Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now This information should be included in your cover letter; we will change the online submission form on your behalf. -We clearly state that the authors have declared that no competing interests exist in cover letter as you recommended. 6. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. -We will provide the access to data such as tables and figures in the manuscript. Reviewers' comments: Review Comments to the Author Reviewer #1: The paper is solid , but the authors could make a stronger case for its importance , as if one is doing a stress test , one already has HRR so why is BP recovery needed . Likewise , why does one need to predict PP when it is so easy to measure by just taking BP? - Thank you for your advice and we can get a lot of data at once by doing an exercise stress test including HRR, serial blood pressure and HR indexes. When evaluating a person's autonomic nerve function, more reliable and objective evidence can be used by using multiple indicators including systolic blood pressure at recovery stage (SBPR) as well as HRR. Although HRR is a well-known indicator, blood pressure that is not easily normalized even after exercise can provide very useful information to suspect autonomic dysfunction. In this study, it is meaningful to show that systolic blood pressure of recovery stage can be a simple indicator that can suspect autonomic nerve abnormalities when blood pressure does not quickly normalize after usual exercise. And as mentioned in the text, it showed that rapid stabilization of blood pressure after exercise was related to arterial stiffness, and through this, systolic blood pressure at recovery stage (SBPR) can give a message that it is not irrelevant to various cardiovascular complications related to vascular stiffness. And we added additional other study results on relationship of SBPR and arterial stiffness to the discussion section (reference 29) Reviewer #2: Dear authors, congratulations for your work about Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group. Your aim is not well defined in the manuscript, it is hard for the reader to understand your goal. You must define with more specification your aim and strenght the need for this study in the literature. "Why is important to do this study?" - Thank you for your advice and we modified and supplemented the aim of this study more clearly in the abstract and introduction section. Furthermore, there was a study result showing the relationship between convalescent blood pressure and cardiovascular events, was added to the reference (reference 32). 32. Laukkanen JA, Willeit P, Kurl S, Mäkikallio TH, Savonen K, Ronkainen K, et al. Elevated systolic blood pressure during recovery from exercise and the risk of sudden cardiac death. J Hypertens. 2014 Mar; 32(3):659-666. Suggestions: 1. Abstract: add sentence with background; Results: rewrite this part and remove statistical procedures; - Thank you. As you pointed out, the background and results were modified and supplemented to make the purpose and results of the study more clear. 2: Introduction: Add more setences about your topic and exercise type and population; Define with more specificity your study aim; - Thank you for your advice and the purpose of the study was added in more detail in the introduction section. We specifically described the exercise type and population in the ‘Materials and Methods’ section. 3: Methods: Add yoiur study design; Add exclusion criteria; Why not perform anova?; Add procedures - Thank you for your advice and we mentioned the study design in the section of ‘Materials and Methods’ including study population which referred for treadmill exercise test for the evaluation of chest pain and they underwent a standard maximal graded exercise treadmill test according to the standard Bruce protocol with a T2100-ST2 Treadmill system. -There is the ‘exclusion criteria’ of this study in ‘study participants’ of ‘Materials and Methods’ section and we added ‘patients under 18 years of age to the exclusion criteria’. ; … Patients under 18 years of age, severe obesity (BMI ≥ 35 Kg/m2), positive treadmill test result, medical history of hypertension, diabetes mellitus, dyslipidemia, any cardiovascular disease, left ventricular dysfunction, valvular heart disease, atrial fibrillation or renal failure were excluded. -Thank you for your advice and we reviewed again all the statistical process of this study as you mentioned. This study did not use student's t test or ANOVA because the cases were not divided into several groups and compared. As the baseline characteristics of all cases, the value of mean and standard deviation or number (%) of each item were shown in Table 1. Pearson’s correlation analysis (Table 2) and a stepwise, multiple regression analysis (Table 3) corrected for several factors were performed to see the correlation with HRR among the entire data. Furthermore, pearson’s correlation analysis was used to see a reasonable relationship of SBP during the recovery period, which were the focus of this study with other hemodynamic variables such as blood pressure, heart rate, pulse pressure or PWV other than HRR (Table 4). 4: Results: redone statistical procedures; -Same as above. 5: Discussion: You need to add more specific literature to debate your results. E.g.:"The increase in heart rate during exercise was proportional to HRR in this group. It can be interpreted that HRR will be good if the HR increases sufficiently much during exercise." what is sufficiently much during exercise? -Thank you. I agree with your opinion. And for better understanding about the sentence you asked, let me explain with Table 2: HRR showed a significant positive correlation with the HR in the peak exercise stage and a significant negative correlation with the HR in the recovery period (the 1st to 2nd minute). This indicates that HR, which rises high during exercise and rapidly decreases during recovery appears as desirable HRR and can represent good autonomic function. We changed this expression you have asked to be more explicit. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0285961.r002
18 Sep 2023 Decision Letter - Damon Leo Swift, Editor Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group PONE-D-23-13242R1 Dear Dr. Yoon, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Damon Leo Swift Academic Editor PLOS ONE Additional Editor Comments (optional): The response to reviewers are adequate for publication Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: Congratulations for your work about this topic. You have attended my suggestions and the manuscript improved. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: Yes: Luis Leitão ******** https://doi.org/10.1371/journal.pone.0285961.r003
Formally Accepted
25 Sep 2023 Acceptance Letter - Damon Leo Swift, Editor PONE-D-23-13242R1 Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group Dear Dr. Yoon: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Damon Leo Swift Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0285961.r004

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