Sex differences in workload-indexed blood pressure response and vascular function among professional athletes and their utility for clinical exercise testing

Repetition-dependent acutecardiopulmonary responses during intensity-matched squats in males

The 'strength-endurance continuum' is a key concept in strength training (ST). Although cardiopulmonary responses have seldom been reported in conjunction with ST, this repeated-measurement study examined acute blood pressure and haemodynamic responses continuously depending on the number of repetitions but without changing the intensity. Fifteen healthy male participants (21.6 (2.0) years; mean (SD)) performed an incremental exercise test and a 3-repetition maximum test (3-RM) on a Smith machine. They were then randomly assigned to three ST sessions involving 10, 20 and 30 repetitions at 50% of their 3-RM. Blood pressure (vascular unloading technique) and cardiopulmonary responses (spirometry and impedance cardiography) were continuously monitored. Heart rate (121 (10) vs. 139 (22) vs. 153 (13) bpm, P = 0.001, respectively), cardiac output (10.4 (1.9) vs. 13.6 (3.8) vs. 14.6 (3.1) L/min, P = 0.001, respectively) and diastolic blood pressure (113 (8) vs. 116 (21) vs. 135 (22) mmHg, P = 0.001, respectively) increased in the training sessions with higher repetitions. Stroke volume, systolic blood pressure and end-diastolic volume indicated no change in peak values between training sessions. Total peripheral resistance (13.6 (2.8) vs. 11.3 (3.6) vs. 11.2 (3.1) mmHg min/L, P = 0.002, respectively) was significantly lower with 20 and 30 repetitions, while oxygen uptake (V ̇ O 2 ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}}}$ : 15.5 (1.9) vs. 20.5 (4.1) vs. 20.6 (4.4) mL/min/kg, P = 0.001, respectively) was significantly higher. ST of moderate intensity with an exhausting number (>20) of repetitions induces strong haemodynamic responses, especially high cardiac afterload and a compensatory heart rate acceleration, which may also create a strong stimulus for cardiopulmonary adaptation.

The Role of Exercise Blood Pressure in Hypertension: Measurement, Mechanisms, and Management

ABSTRACT

Hypertension affects one in three adults globally and is the leading modifiable risk factor for cardiovascular disease. Although blood pressure measurements at rest are fundamental to the detection and management of hypertension, abnormal blood pressure responses to exercise, namely, an exaggerated exercise blood pressure (EEBP), can provide additional independent information about current and future hypertension risk. This paper summarizes a symposium entitled, "The Role of Exercise Blood Pressure in Hypertension: Measurement, Mechanisms and Management" included at the 2023 American College of Sports Medicine annual meeting, which presented a timely discussion about the clinical utility of EEBP. Here we will summarize the evidence presented by the speakers including considerations for blood pressure measurement during exercise, an overview of EEBP thresholds and discussion about the value of EEBP during submaximal exercise for the identification and management of hypertension, a summary of the potential physiological mechanisms underpinning an EEBP, and a review of exercise prescription guidelines based on new and emerging evidence as they relate to the American College of Sports Medicine's exercise recommendations for hypertension. We conclude by highlighting areas for future research with the overarching goal of improving the measurement and management of hypertension.

Blood pressure response to graded bicycle exercise in males and females across the age and fitness spectrum

AIMS

Blood pressure (BP) responses to exercise are frequently measured, with the concern that greater increases are a marker of disease. We sought to characterize the normal exercise BP response in healthy adults and its relationships with age, sex, and fitness.

METHODS AND RESULTS

Five hundred and eighty-nine participants [median age 46 (interquartile range 24-56) years, 81% male] underwent cardiopulmonary exercise testing with repeated, automated BP measures. An exaggerated maximal systolic BP (SBPmax) was defined from current guidelines as ≥210 mmHg in males and ≥190 mmHg in females. Individual linear regression analyses defined the relationship between BP and workload (W; SBP/W-slope and DBP/W-slope). Participants with or without an exaggerated SBPmax and above- or below-median SBP/W-slope were compared. An exaggerated SBPmax was found in 51% of males and 64% of females and was more prevalent in endurance-trained athletes (males 58%, females 72%, P < 0.001). The mean SBP/W-slope was lower in males (0.24 ± 0.10 mmHg/W) than females (0.27 ± 0.12 mmHg/W, P = 0.031). In both sexes, peak oxygen uptake (VO2peak) was inversely correlated with SBP/W-slope (P < 0.01). Those with an exaggerated SBPmax and below-median SBP/W-slope were 10 years younger and had a 20% higher VO2peak, on average (P < 0.001). A non-exaggerated SBPmax and above-median SBP/W-slope was observed in older individuals with the lowest VO2peak.

CONCLUSION

In a large cohort of healthy individuals, an exaggerated SBPmax was common and associated with higher fitness. In contrast, higher SBP indexed to W was associated with older age, lower fitness, and female sex. Thus, sex, age, and fitness should be considered when evaluating BP response to exercise.

REGISTRATION

Pro@Heart: NCT05164328, ACTRN12618000716268; ProAFHeart: ACTRN12618000711213; Master@Heart: NCT03711539.

Association of aortic root diameter and vascular function with an exaggerated blood pressure response to exercise among elite athletes

BACKGROUND

The systolic blood pressure/workload (SBP/MET) slope was recently reported to reliably identify an exaggerated blood pressure response (eBPR) in the normal population and in athletes. We investigated whether the aortic root diameter (AoD) also correlates with an eBPR and vascular function in elite athletes.

METHODS

We examined 652 healthy male elite athletes (age 25.8 ± 5 years) of mixed sports with a standardized maximum exercise test. Central blood pressure and vascular function were measured non-invasively with a validated oscillometric device. The SBP/MET slope was calculated and the threshold for an eBPR was set at > 6.2 mmHg/MET. Two groups were defined (≤ 6.2 and > 6.2 mmHg/MET), and an association between AoD and vascular function with the SBP/MET slope was evaluated for each group.

RESULTS

Athletes with an eBPR (n = 191, 29%) displayed a higher systolic central BP (103 ± 7.7 vs. 101 ± 9.2 mmHg, p = 0.004), larger AoD (32.8 ± 3.3 vs. 31.9. ± 3.2 mm, p < 0.001), a higher AoD/left ventricular end-diastolic diameter (LVEDD) ratio (0.62 ± 0.061 vs. 0.59. ± 0.056, p < 0.001), a lower LVEDD/AoD ratio (1.64 ± 0.16 vs. 1.69. ± 0.16, p < 0.001), and a lower absolute (299 ± 59 vs. 379 ± 65 W, p < 0.001) and relative workload (3.17 ± 0.55 vs. 4.05 ± 1.2 W/kg, p < 0.001) vs. athletes with a normal SBP/MET slope (n = 461, 71%). No differences between the two groups were found after indexing AoD to body surface area (BSA) (14.76 ± 1.36 vs. 14.73 ± 1.41, p = 0.772).

CONCLUSION

Athletes with eBPR displayed altered AoD/LVEDD and LVEDD/AoD ratios, whereas AoD/BSA indexing was not different. Further longitudinal studies are encouraged to explore these metrics and their role in aortic remodeling of athletes.

Peak systolic blood pressure during preparticipation exercise testing in 12,083 athletes: age, sex, and workload-indexed values and predictors

Aim

Assessment of blood pressure during exercise is routine in athletes, but normal values remain equivocal. This study examines the response of systolic blood pressure (SBP) to exercise in a large cohort of athletes and establishes normative values by sex and age.

Methods

Competitive athletes free of cardiovascular disease underwent pre-participation exercise testing on a bicycle ergometer. Resting (SBPrest) and peak blood pressure (SBPpeak), heart rate (HRrest and HRpeak), and power output (WR) were recorded. Workload indexed values were calculated.

Results

The cohort included 12,083 athletes (median age 15 years, 26.9% female). Median peak exercise SBP was similar between sexes, but WR-indexed measures including SBP/WR ratio and SBP/(WR/kg) slope were higher in females (0.9 vs. 0.7, p < 0.001; 10.94 vs. 9.52, p < 0.001). Univariate analyses revealed significant associations between SBPpeak and several predictors, including sex, age, weight, height, SBPrest, DBPrest, HRrest, HRpeak, and WR (all p < .001). Multivariate analysis showed that SBPrest (beta = 0.353, 95% CI [0.541, 0.609], p < 0.001), height (beta = 0.303, 95% CI [0.360, 0.447], p < 0.001), WR (beta = 0.171, 95% CI [0.029, 0.045], p < 0.001), and age (beta = 0.093, 95% CI [0.162, 0.241], p < 0.001) were the strongest predictors of SBPpeak.

Conclusion

This study provides reference values for the interpretation of SBP responses to exercise in athletes. Multivariate analyses highlight the complex interplay of factors influencing peak SBP, including SBPrest, height, WR, age, DBPrest, sex, endurance sport category, and weight. In future studies, these findings may inform the development of personalised training strategies and risk stratification models in athletic populations.

Consideration of absolute intensity when examining sex differences in blood pressure responses during static exercise

Low- to moderate-intensity submaximal static contractions are commonly used to study the effects of biological sex on the cardiovascular response to exercise. Under this paradigm, premenopausal females frequently demonstrate smaller blood pressure responses than age-matched males. These differences are preserved during postexercise circulatory occlusion, implicating the muscle metaboreflex as an important driver of sex differences in the blood pressure response to static exercise. The mechanisms responsible for these differences are incompletely understood but often attributed to innate sex differences in skeletal muscle fiber type distribution, muscle metabolism, and/or sympathetic control of the circulation. However, one potential confounding factor is that the majority of studies use relative intensity exercise (e.g., 30% of maximal voluntary contraction), such that on average, females are completing static contractions at a lower absolute intensity. In this review, we summarize human evidence showing that sex differences in blood pressure responses to static exercise are attenuated or abolished when controlling for absolute intensity and muscle strength, either by statistical methods or strength-matched cohorts. We highlight evidence that the effect of higher absolute contraction intensity on exercise blood pressure likely occurs through increased mechanical occlusion of skeletal muscle microvasculature, leading to greater activation of the muscle metaboreflex. These findings highlight an important need to account for absolute intensity when studying and interpreting sex differences in cardiovascular responses to exercise.

Definitions for Hypertensive Response to Exercise

Broad evidence indicates that hypertensive response to exercise (HRE) is associated with future hypertension (aHT) at rest and cardiovascular morbidity and mortality. Nevertheless, a consensus on the definition of HRE is lacking and the comparability of the available data is difficult due to a wide variation of definitions used. This review aims to harmonize currently available definitions of HRE in normotensive and athletic populations and to propose a generally valid cut-off applicable in everyday clinical practice. A literature search on PubMed and Embase was conducted to assemble and analyze the most recent data. Various definitions of HRE were identified and linked with future cardiovascular diseases. Forty-one studies defined HRE at a peak systolic blood pressure (SBP) above or equal to 200 mmHg in men and 25 studies for 190 mmHg in women. Peak diastolic blood pressure (DBP) between 90 and 110 mmHg was reported in 14 studies, relative DBP increase in four. Eight studies defined HRE as SBP between 160 and 200 mmHg at 100 watts. 17 studies performed submaximal exercise testing, while two more looked at BP during recovery. A plethora of other definitions was identified. In athletes, total workload and average blood pressure during exercise were considerably higher. Based on the presented data, the most commonly used definition of HRE at peak exercise is 210/105 mmHg for men, 190/105 mmHg for women, and 220/210 mmHg for athletes. Furthermore, a uniform exercise testing protocol, a position statement by leading experts to unify the definition of HRE, and prospective studies are warranted to confirm these cut-offs and the associated morbidity and mortality.

Association of central blood pressure with an exaggerated blood pressure response to exercise among elite athletes

PURPOSE

The systolic blood pressure/workload (SBP/MET) slope was recently reported to be a reliable parameter to identify an exaggerated blood pressure response (eBPR) in the normal population and in athletes. However, it is unclear whether an eBPR correlates with central blood pressure (CBP) and vascular function in elite athletes.

METHODS

We examined 618 healthy male elite athletes (age 25.8 ± 5.1 years) of mixed sports with a standardized maximum exercise test. CBP and vascular function were measured non-invasively with a validated oscillometric device. The SBP/MET slope was calculated and the threshold for an eBPR was set at > 6.2 mmHg/MET. Two groups were defined according to ≤ 6.2 and > 6.2 mmHg/MET, and associations of CBP and vascular function with the SBP/MET slope were compared for each group.

RESULTS

Athletes with an eBPR (n = 180, 29%) displayed a significantly higher systolic CBP (102.9 ± 7.5 vs. 100 ± 7.7 mmHg, p = 0.001) but a lower absolute (295 ± 58 vs. 384 ± 68 W, p < 0.001) and relative workload (3.14 ± 0.54 vs. 4.27 ± 1.1 W/kg, p < 0.001) compared with athletes with a normal SBP/MET slope (n = 438, 71%). Systolic CBP was positively associated with the SBP/MET slope (r = 0.243, p < 0.001). In multiple logistic regression analyses, systolic CBP (odds ratio [OR] 1.099, 95% confidence interval [CI] 1.045-1.155, p < 0.001) and left atrial volume index (LAVI) (OR 1.282, CI 1.095-1.501, p = 0.002) were independent predictors of an eBPR.

CONCLUSION

Systolic CBP and LAVI were independent predictors of an eBPR. An eBPR was further associated with a lower performance level, highlighting the influence of vascular function on the BPR and performance of male elite athletes.

Cardiovascular responses to combined mechanoreflex and metaboreflex activation in healthy adults: effects of sex and low- versus high-hormone phases in females

Females generally have smaller blood pressure (BP) responses to isolated muscle mechanoreflex and metaboreflex activation compared with males, which may explain sex differences in BP responses to voluntary exercise. The mechanoreflex may be sensitized during exercise, but whether mechanoreflex-metaboreflex interactions differ by sex or variations in sex hormones remains unknown. Thirty-one young healthy subjects (females, n = 16) performed unilateral passive cycling (mechanoreflex), active cycling (40% peak Watts), postexercise circulatory occlusion (PECO; metaboreflex), and passive cycling combined with PECO (combined mechanoreflex and metaboreflex activation). Beat-to-beat BP, heart rate, inactive leg vascular conductance, and active leg muscle oxygenation were measured. Ten females underwent exploratory testing during low- and high-hormone phases of their self-reported menstrual cycle or oral contraceptive use. Systolic BP and heart rate responses did not differ between sexes during active cycling [Δ30 ± 9 vs. 29 ± 11 mmHg (males vs. females), P = 0.9; Δ33 ± 8 vs. 35 ± 6 beats/min, P = 0.4] or passive cycling with PECO (Δ26 ± 11 vs. 21 ± 10 mmHg, P = 0.3; Δ14 ± 7 vs. 18 ± 15 beats/min, P = 0.3). Passive cycling with PECO revealed additive, not synergistic, effects for systolic BP [males: Δ23 ± 14 vs. 26 ± 11 mmHg (sum of isolated passive cycling and PECO vs. combined activation); females: Δ26 ± 11 vs. 21 ± 12 mmHg, interaction P = 0.05]. Results were consistent in subset analyses with sex differences in active cycling BP (P > 0.1) and exploratory analyses of hormone phase (P > 0.4). Despite a lack of statistical equivalence, no differences in cardiovascular responses were found during combined mechanoreflex-metaboreflex activation between sexes or hormone levels. These results provide preliminary data regarding the involvement of muscle mechanoreflex-metaboreflex interactions in mediating sex differences in voluntary exercise BP responses.NEW & NOTEWORTHY The muscle mechanoreflex may be sensitized by metabolites during exercise. We show that cardiovascular responses to combined mechanoreflex (passive cycling) and metaboreflex (postexercise circulatory occlusion) activation are primarily additive and do not differ between males and females, or across variations in sex hormones in females. Our findings provide new insight into the contributions of muscle mechanoreflex-metaboreflex interactions as a cause for prior reports that females have smaller blood pressure responses to voluntary exercise.

Deep phenotype characterization of hypertensive response to exercise: implications on functional capacity and prognosis across the heart failure spectrum

AIMS

Limited evidence is available regarding the role of hypertensive response to exercise (HRE) in heart failure (HF). We evaluated the systolic blood pressure (SBP) to workload slope during exercise across the HF spectrum, investigating haemodynamic and prognostic correlates of HRE.

METHODS AND RESULTS

We prospectively enrolled 369 patients with HF Stage C (143 had preserved [HFpEF], and 226 reduced [HFrEF] ejection fraction), 201 subjects at risk of developing HF (HF Stages A-B), and 58 healthy controls. We performed a combined cardiopulmonary exercise stress echocardiography testing. We defined HRE as the highest sex-specific SBP/workload slope tertile in each HF stage. Median SBP/workload slope was 0.53 mmHg/W (interquartile range 0.36-0.72); the slope was 39% steeper in women than men (p < 0.0001). After adjusting for age and sex, SBP/workload slope in HFrEF (0.47, 0.30-0.63) was similar to controls (0.43, 0.35-0.57) but significantly lower than Stages A-B (0.61, 0.47-0.75) and HFpEF (0.63, 0.42-0.86). Patients with HRE showed significantly lower peak oxygen consumption and peripheral oxygen extraction. After a median follow-up of 16 months, HRE was independently associated with adverse outcomes (all-cause mortality and hospitalization for cardiovascular reasons: hazard ratio 2.05, 95% confidence interval 1.81-5.18), while rest and peak SBP were not. Kaplan-Meier analysis confirmed a worse survival probability in Stages A-B (p = 0.005) and HFpEF (p < 0.001), but not HFrEF.

CONCLUSION

A steeper SBP/workload slope is associated with impaired functional capacity across the HF spectrum and could be a more sensitive predictor of adverse events than absolute SBP values, mainly in patients in Stages A-B and HFpEF.

Reliability of blood pressure responses used to define an exaggerated blood pressure response to exercise in young healthy adults

Exaggerated blood pressure (BP) responses (EBPR) to exercise are prognostic of future cardiovascular risk. The primary objective of this study was to assess the test-retest reliability of BP responses used to categorize EBPR as absent or present. Twenty-seven healthy adults [21(2) years; 12 males] with resting BP < 130/80 mmHg completed a modified Bruce protocol treadmill exercise test on two visits separated by 6 (3) days. BP measurements were obtained during exercise using an automated auscultatory device. Submaximal and maximal systolic and diastolic BP, the change in diastolic BP from rest to maximal diastolic BP, and the change in systolic BP relative to the change in exercise intensity, quantified using the metabolic equivalent of task (SBP/MET-slope) were determined. Test-retest reliability of these BP responses was assessed using intraclass correlation coefficients (ICC) with a value ≥0.61 considered as substantial reliability. Submaximal diastolic BP demonstrated substantial reliability in the total group (ICC = 0.670; P ≤ 0.001). In males, submaximal systolic BP (ICC = 0.655, P < 0.01), submaximal diastolic BP (ICC = 0.699; P < 0.01) and maximal systolic BP (ICC = 0.794; P ≤ 0.001) demonstrated substantial reliability. All other BP responses were not reliable. Despite the prognostic value of EBPR, only three BP responses used to categorize EBPR demonstrated substantial test-retest reliability in healthy young males. In clinical practice, these preliminary findings would support the use of exercise BPs to identify young males with elevated cardiovascular risk, but additional research is needed to improve the clinical utility of exercise BPs and EBPR in females.

Exercise Hypertension in Athletes

Background: An exaggerated blood pressure response (EBPR) during exercise testing is not well defined, and several blood pressure thresholds are used in different studies and recommended in different guidelines. Methods: Competitive athletes of any age without known arterial hypertension who presented for preparticipation screening were included in the present study and categorized for EBPR according to American Heart Association (AHA), European Society of Cardiology (ESC), and American College of Sports Medicine (ACSM) guidelines as well as the systolic blood pressure/MET slope method. Results: Overall, 1137 athletes (mean age 21 years; 34.7% females) without known arterial hypertension were included April 2020−October 2021. Among them, 19.6%, 15.0%, and 6.8% were diagnosed EBPR according to ESC, AHA, and ACSM guidelines, respectively. Left ventricular hypertrophy (LVH) was detected in 20.5% of the athletes and was approximately two-fold more frequent in athletes with EBPR than in those without. While EBPR according to AHA (OR 2.35 [95%CI 1.66−3.33], p < 0.001) and ACSM guidelines (OR 1.81 [95%CI 1.05−3.09], p = 0.031) was independently (of age and sex) associated with LVH, EBPR defined according to ESC guidelines (OR 1.49 [95%CI 1.00−2.23], p = 0.051) was not. In adult athletes, only AHA guidelines (OR 1.96 [95%CI 1.32−2.90], p = 0.001) and systolic blood pressure/MET slope method (OR 1.73 [95%CI 1.08−2.78], p = 0.023) were independently predictive for LVH. Conclusions: Diverging guidelines exist for the screening regarding EBPR. In competitive athletes, the prevalence of EBPR was highest when applying the ESC (19.6%) and lowest using the ACSM guidelines (6.8%). An association of EBPR with LVH in adult athletes, independently of age and sex, was only found when the AHA guideline or the systolic blood pressure/MET slope method was applied.

Systolic Blood Pressure Response to Exercise in Endurance Athletes in Relation to Oxygen Uptake, Work Rate and Normative Values

Work rate has a direct impact on the systolic blood pressure (SBP) during aerobic exercise, which may be challenging in the evaluation of the SBP response in athletes reaching high work rates. We aimed to investigate the exercise SBP response in endurance athletes in relation to oxygen uptake (VO2), work rate and to recent reference equations for exercise SBP in the general population. Endurance athletes with a left-ventricular end-diastolic diameter above the reference one performed a maximal bicycle cardiopulmonary exercise test. The increase in SBP during exercise was divided by the increase in VO2 (SBP/VO2 slope) and in Watts, respectively (SBP/W slope). The maximum SBP (SBPmax) and the SBP/W slope were compared to the predicted values. In total, 27 athletes (59% men) were included; mean age, 40 ± 10 years; mean VO2max, 50 ± 5 mL/kg/min. The mean SBP/VO2 slope was 29.8 ± 10.2 mm Hg/L/min, and the mean SBP/W slope was 0.27 ± 0.08 mm Hg/W. Compared to the predicted normative values, athletes had, on average, a 12.2 ± 17.6 mm Hg higher SBPmax and a 0.12 ± 0.08 mm Hg/W less steep SBP/W slope (p < 0.01 and p < 0.001, respectively). In conclusion, the higher SBPmax values and the less steep SBP/W slope highlight the importance of considering work rate when interpreting the SBP response in endurance athletes and suggest a need for specific normative values in athletes to help clinicians distinguish physiologically high maximal blood pressure from a pathological blood pressure response.

Sex-Based Differences in Peak Exercise Blood Pressure Indexed to Oxygen Consumption Among Competitive Athletes

PURPOSE

Although exercise testing guidelines define cutoffs for an exaggerated exercise systolic blood pressure (SBP) response, SBPs above these cutoffs are not uncommon in athletes given their high exercise capacity. Alternately, guidelines also specify a normal SBP response that accounts for metabolic equivalents (METs; mean [SD] of 10 [2] mm Hg per MET or 3.5 mL/kg/min oxygen consumption [V˙o₂]). SBP and V˙o₂ increase less during exercise in females than males. It is not clear if sex-based differences in exercise V˙o₂ are related to differences in SBP or if current recommendations for normal increase in SBP per MET produce reasonable estimates using measured METs (ie, V˙o₂) in athletes. We therefore examined sex-based differences in exercise SBP indexed to V˙o₂ in athletes with the goal of defining normative values for exercise SBP that account for fitness and sex.

METHODS

Using prospectively collected data from a single sports cardiology program, normotensive athlete patients were identified who had no relevant cardiopulmonary disease and had undergone cardiopulmonary exercise testing with cycle ergometry or treadmill. The relationship between ΔSBP (peak - rest) and ΔV˙o₂ (peak - rest) was examined in the total cohort and compared between sexes.

FINDINGS

A total of 413 athletes (mean [SD] age, 35.5 [14] years; 38% female; mean [SD] peak V˙o₂, 46.0 [10.2] mL/kg/min, 127% [27%] predicted) met the inclusion criteria. The ΔSBP correlated with unadjusted ΔV˙o₂ (cycle: R² = 0.18, treadmill: R² = 0.12; P < 0.0001). Female athletes had lower mean (SD) peak SBP (cycle: 161 [15] vs 186 [24] mm Hg; treadmill: 165 [17] vs 180 [20] mm Hg; P < 0.05) than male athletes. Despite lower peak SBP, mean (SD) ΔSBP relative to unadjusted ΔV˙o₂ was higher in female than male athletes (cycle: 25.6 [7.2] vs 21.1 [7.3] mm Hg/L/min; treadmill: 21.6 [7.2] vs 17.0 [6.2] mm Hg/L/min; P < 0.05). When V˙o₂ was adjusted for body size and converted to METs, female and male athletes had similar mean (SD) ΔSBP /ΔMET (cycle: 6.0 [2.1] vs 5.8 [2.0] mm Hg/mL/kg/min; treadmill: 4.7 [1.8] vs 4.8 [1.7] mm Hg/mL/kg/min).

IMPLICATIONS

In this cohort of athletes without known cardiopulmonary disease, observed sex-based differences in peak exercise SBP were in part related to the differences in ΔV˙o₂ between male and female athletes. Despite lower peak SBP, ΔSBP/unadjusted ΔV˙o₂ was paradoxically higher in female athletes. Future work should define whether this finding reflects sex-based differences in the peripheral vascular response to exercise. In this athletic cohort, ΔSBP/ΔMET was similar between sexes and much lower than the ratio that has been proposed by guidelines to define a normal SBP response. Our observed ΔSBP/ΔMET, based on measured rather than estimated METs, provides a clinically useful estimate for normal peak SBP range in athletes.

Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing

ABSTRACT

We propose that for correct clinical interpretation of exaggerated exercise blood pressure (EEBP), both cardiorespiratory fitness and exercise workload must be considered. A key recommendation towards achieving the correct clinical interpretation of EEBP is that exercise BP should be measured during submaximal exercise with a fixed external workload.

Low but not high exercise systolic blood pressure is associated with long-term all-cause mortality

Objectives

The risks associated with achieving a high peak systolic blood pressure (SBP) during clinical exercise testing remain controversial, although this issue has not been evaluated in relation to predicted SBP standards. This cohort study aimed to evaluate the long-term risk of all-cause mortality in males in relation to reference values of peak SBP and the increase in SBP during exercise from the Fitness Registry and the Importance of Exercise: A National Database (FRIEND).

Methods

We followed 7164 males (mean age: 58.2±10.6 years) over 95 998 person-years of follow-up (mean 13.4±5.4 years), who performed a maximal treadmill exercise test at baseline. SBP was measured at rest and at peak exercise. Risk of all-cause mortality over 20 years (Cox regression) was determined in relation to reference percentiles of peak SBP and increase in SBP with exercise: <10th (low), 10th-90th, >90th (high) percentiles.

Results

A high peak or a large increase in SBP with exercise was not associated with all-cause mortality. Subjects with a low peak SBP had a 20% higher unadjusted risk for all-cause death compared with those with a normal value (1.20 (1.11-1.31)), and a statistically non-significant 7% higher risk after adjustment for all baseline risk factors (1.07 (0.97-1.18)). The corresponding unadjusted and adjusted risks associated with a low increase in SBP were 1.24 (1.15-1.35) and 1.11 (1.02-1.21), respectively.

Conclusions

A low-but not high-peak SBP is associated with increased unadjusted risk of all-cause mortality. The FRIEND percentiles of exercise SBP can aid clinicians in individualising risk assessment.