Low exercise blood pressure and risk of cardiovascular events and all-cause mortality: systematic review and meta-analysis

Patterns of systolic blood pressure response at the end of exercise and mortality and morbidity in patients referred for exercise testing

OBJECTIVES

Peak exercise systolic blood pressure (SBP) is associated with future cardiovascular disease (CVD) and mortality. We aimed to evaluate the predictive value of different SBP patterns at the end of exercise with these outcomes.

METHODS

We studied 6329 adults (45% women) referred for exercise testing, with test duration of 6-14 min, maximal effort and valid SBP measurements at the end of exercise. The two last SBPs were indexed to work rate (mmHg/Watt), defining responses as: drop (negative change), plateau (no change), slow (lower tertile of increase), intermediate (middle tertile) and steep (upper tertile). Data were cross-linked with nationwide disease and mortality registries. Associations with all-cause mortality and incident CVD were analysed using Cox proportional hazards regression (hazard ratio (HR), 95% confidence interval), using slow SBP increase as reference, adjusted for sex, age, body mass index, baseline CVD (mortality analysis only), beta-blockers and exercise capacity (peak Watt).

RESULTS

The prevalence of SBP responses at the end of exercise were drop (1.1%), plateau (15.0%), slow (30.4%), intermediate (25.2%) and steep increase (28.3%). Follow-up was 8.8±3.4 years. Compared with a slow increase, the adjusted all-cause mortality risks were not statistically different for a drop (HR 1.16 (0.50-2.65)), plateau (HR 1.19 (0.85-1.66)), intermediate (HR 1.24 (0.93-1.66)) or steep SBP increase (HR 1.16 (0.89-1.52)). CVD risk was increased in those with a SBP drop (HR 3.10 (1.85-5.19), but not significantly for plateau (HR 1.17 (0.92-1.48)), intermediate or steep SBP increases (HRs 0.99-1.00).

CONCLUSION

Subjects with a slow SBP increase at the end of exercise tended to have the lowest mortality risk, although no SBP response pattern predicted all-cause mortality independently. CVD risk was strongly increased in patients with a drop in SBP and tended to be increased (non-significantly) also in patients with a plateau in SBP at the end of exercise, in comparison with increasing SBP.

Hypertensive Response to Exercise as an Early Marker of Disease Development

Arterial hypertension is one of the world's leading risk factors for death and disability. With the number of people living with this disease doubling between 1990 and 2019 from 650 million to 1.3 billion, it is a global burden that increases mortality from cardiovascular and kidney diseases. It is extremely important to use all possible diagnostic methods, indicating the possibility of early detection that subsequently leads to effective prevention of disease development. The phenomenon called hypertensive response to exercise (HRE) is one such method. The HRE is defined as a pathological, excessive increase in blood pressure as a result of exposure to the stressor, which is physical exercise. There is no consensus about precise cutoffs in the definition of this condition, which is most commonly diagnosed based on systolic blood pressure (SBP) ≥ 210 mm Hg in men and ≥190 mm Hg in women at peak exercise intensity. The fact that exercise hypotension is a pathologic sign is universally accepted. Accumulating data deliver the information that HRE is also connected to higher overall cardiovascular risk. It was demonstrated that HRE is associated with functional and structural impairment of the left ventricle and the future development of hypertension. HRE should act as a warning signal of increased cardiovascular risk, leading to the need for profound clinical care.

Exercise blood pressure, cardiorespiratory fitness, fatness and cardiovascular risk in children and adolescents

Cardiovascular disease remains the leading cause of mortality on a global scale. Individuals who possess risk factors for cardiovascular disease, such as high blood pressure (BP) and obesity, face an elevated risk of experiencing organ-specific pathophysiological changes. This damage includes pathophysiological changes in the heart and peripheral vascular systems, such as ventricular hypertrophy, arterial stiffening, and vascular narrowing and stenosis. Consequently, these damages are associated with an increased risk of developing severe cardiovascular outcomes including stroke, myocardial infarction, heart failure, and coronary heart disease. Among all the risk factors associated with cardiovascular disease, high blood pressure emerges as the most prominent. However, conventional resting BP measurement methods such as auscultatory or oscillometric methods may fail to identify many individuals with asymptomatic high BP. Recently, exercise BP has emerged as a valuable diagnostic tool for identifying real (high) blood pressure levels and assessing underlying cardiovascular risk, in addition to resting BP measurements in adults. Furthermore, numerous established factors, such as low cardiorespiratory fitness and high body fatness, have been confirmed to contribute to exercise BP and the associated cardiovascular risk. Modifying these factors may help reduce high exercise BP and, consequently, alleviate the burden of cardiovascular disease. A significant body of evidence has demonstrated cardiovascular disease in later life have their origins in early life. Children and adolescents with these cardiovascular risk factors also possess a greater propensity to develop cardiovascular diseases later in life. Nevertheless, the majority of previous studies on the clinical utility of exercise BP have been conducted in middle-to-older aged populations, often with pre-existing clinical conditions. Therefore, there is a need to investigate further of the factors influencing exercise BP in adolescence and its association with cardiovascular risk in early life. Our previously published work showed that exercise BP is a potential useful method to detect adolescents with increased cardiovascular risk. Children and adolescents with cardiovascular risk factors are more likely to develop cardiovascular diseases later in life. However, previous studies on the clinical utility of exercise BP have largely focused on middle-to-older aged populations with pre-existing clinical conditions. Therefore, there is a need to investigate further the factors influencing exercise BP in adolescence and its association with future cardiovascular risk. Our previous studies, which focused on exercise BP measured at submaximal intensity, have shown that exercise BP is a potentially useful method for identifying adolescents at increased cardiovascular risk. Our previous findings suggest that improving cardio-respiratory fitness and reducing body fatness may help to reduce the risk of developing cardiovascular disease and improve overall cardiovascular health. These findings have important implications for the development of effective prevention and early detection strategies, which can contribute to improved public health outcomes.

Prognostic Significance of Blood Pressure at Rest and After Performing the Six-Minute Walk Test in Patients With Acute Heart Failure

BACKGROUND

It remains unclear whether systolic (SBP) and diastolic (DBP) pressure and BP response after six-minute walk test (6MWT) are associated with adverse outcomes in patients with acute heart failure (AHF).

METHODS

We investigated these associations in 98 AHF patients (24.5% women; mean age, 70.5 years) enrolled in the ROSE trial (The Low-dose Dopamine or Low-dose Nesiritide in Acute Heart Failure with Renal Dysfunction). The primary endpoint consisted of any death or rehospitalization within 6 months after randomization. We computed hazard ratios (HRs) of the risks associated with 1-SD increase in post-exercise BP levels and BP ratios, calculated as BP immediately after 6MWT divided by BP before 6MWT.

RESULTS

The BP before and after 6MWT averaged 110.6/117.5 mm Hg for SBP and 61.9/64.7 mm Hg for DBP. In multivariable-adjusted analyses including clinic BP measured at the same day of 6MWT, higher DBP after 6MWT was associated with lower risk of the primary endpoint (HR, 0.49; 95% confidence interval [CI], 0.26-0.95; P = 0.034). Both higher SBP and DBP immediately after 6MWT were associated with lower risk of 6-month mortality (HRs, 0.39/0.16; 95% CI, 0.17-0.90/0.065-0.40; P ≤ 0.026). The post-exercise SBP ratio was associated with the risk of 6-month mortality in multivariable-adjusted analyses (HR, 0.44; P = 0.023).

CONCLUSIONS

Higher BP levels and BP ratios immediately after 6MWT conferred lower risk of adverse health outcomes. Our observations highlight that 6MWT-related BP level and response may refine risk estimates in patients hospitalized AHF and may help further investigation for the development of HF preventive strategies.

Age-related alterations in the cardiovascular responses to acute exercise in males and females: role of the exercise pressor reflex

Autonomic adjustments of the cardiovascular system are critical for initiating and sustaining exercise by facilitating the redistribution of blood flow and oxygen delivery to meet the metabolic demands of the active skeletal muscle. Afferent feedback from active skeletal muscles evokes reflex increases in sympathetic nerve activity and blood pressure (BP) (i.e., exercise pressor reflex) and contributes importantly to these primary neurovascular adjustments to exercise. When altered, this reflex contributes significantly to the exaggerated sympathetic and BP response to exercise observed in many cardiovascular-related diseases, highlighting the importance of examining the reflex and its underlying mechanism(s). A leading risk factor for the pathogenesis of cardiovascular disease in both males and females is aging. Although regular exercise is an effective strategy for mitigating the health burden of aging, older adults face a greater risk of experiencing an exaggerated cardiovascular response to exercise. However, the role of aging in mediating the exercise pressor reflex remains highly controversial, as conflicting findings have been reported. This review aims to provide a brief overview of the current understanding of the influence of aging on cardiovascular responses to exercise, focusing on the role of the exercise pressor reflex and proposing future directions for research. We reason that this review will serve as a resource for health professionals and researchers to stimulate a renewed interest in this critical area.

Physical Activity among Rural Residents in Eastern, Central, and Western Provinces of China: A Cross-Sectional Survey

Physical activity (PA) in which physical exercise (PE) is an important component is probably the most important intervention for preventing noncommunicable diseases (NCDs). However, few studies on PA and PE of rural residents in China were reported. This study conducted the first population-based cross-sectional survey in three provinces of China in 2021 that examined both PA and PE as well as the associated factors of rural residents. The International Physical Activity Questionnaire Short Form (IPAQ-S) was used, and a total of 3780 rural residents were surveyed. The result showed that 22.2% of the rural residents were physical inactivity and rural residents reporting practice of PE was 54.4%. Binary logistic regression analyses showed that being female, people aged between 15 to 34 years or 60 years old and above, employees of governmental departments/retirees, school students, the unemployed, and people with NCDs were risk factors of PA while ethnic minority groups, smoking, and alcohol consumption were risk factors of PE. Health promotion programme aiming at increasing people's PA in rural China is urgently needed, and it should focus on the population groups of the female, people aged 60 years and above, school students, the unemployed, and people with NCDs.

Assessing cardiovascular parameters and risk factors in physical therapy practice: findings from a cross-sectional national survey and implication for clinical practice

BACKGROUND

Cardiovascular diseases are the leading cause of death and comorbidity worldwide. High blood pressure and resting heart rate are risk factors (or vital signs) critical to cardiovascular health, patient safety, and medical management. Physiotherapists play a fundamental role in risk factor identification, early diagnosis, and subsequent management of cardiovascular disease. To date there is limited research in Europe investigating the level of knowledge and skills possessed by physiotherapists regarding cardiovascular disease screening. Three studies previously observed inadequate vital signs screening behaviors of physiotherapists practicing in the United States and Saudi Arabia. The primary aim of this study was to investigate cardiovascular knowledge and screening practices among Italian physiotherapists, according to the current practice recommendations.

METHODS

A Cross-Sectional Survey was developed adapting two previous surveys. The survey was administered to members of the Italian Physiotherapy Association. Chi squared test, Mann-Whitney test or Kruskal-Wallis test were used to study differences among subgroups and question responses.

RESULTS

The required sample size was met with total of 387 Italian physiotherapists completing the survey. 80% consider relevant cardiovascular assessment. However, 72.2% were not familiar to guidelines recommendations and only 50% screen vital signs routinely. Their knowledge of normative blood pressure (high-normal, 16%; hypertension, 12%) and heart rate values (bradycardia, 24%; tachycardia, 26%) were low. Although participants reported being skilled for blood pressure measurement (quite sure, 52%; sure, 27%), their adherence to guidelines is low (baseline measurement on both arm, 25%; 3 repeated measures, 46%). Only 27.8% reported to measure exercise related BP and 21.3% of them understood the concept of exaggerated BP. No significant differences between subgroups were found.

CONCLUSIONS

Our study revealed that a concerning proportion of Italian physiotherapists are not versed in fundamentals of properly performing cardiovascular screenings. This lack of knowledge is present across the profession and may impact on appropriate triage and management. The poorly executed screening has the potential to negatively impact the patient and the practitioner. Given the absence of Italian guidelines, we produced and implemented three infographics for public use, which have the dual objective of raising awareness about this subject and providing practical resources for everyday practice.

Hypotension on cardiopulmonary stress test predicts 90 day mortality after LVAD implantation in INTERMACS 3-6 patients

AIMS

Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation.

METHODS AND RESULTS

This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90 days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63 years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90 day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P = 0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup.

CONCLUSIONS

Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90 day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.

Validation of prognostic value of the hemodynamic gain index in different groups of patients undergoing exercise stress testing

Background:

Recently, the hemodynamic gain index (HGI) has shown to be a strong independent predictor of all-cause mortality and associated with metabolic equivalents (METs) in a cohort of male patients. However, the prognostic implications of the HGI have never been externally validated with subgroup analyses based on gender, body mass index (BMI) of 35 kg/m², history of heart failure (HF), coronary artery disease (CAD) and beta-blocker use.

Methods:

We identified 126,356 consecutive patients undergoing treadmill exercise testing between January 1st, 1991 and February 27th, 2015. HGI was calculated using the formula: [(SBP_peak × HR_peak) − (SBP_rest × HR_rest)] / (SBP_rest × HR_rest). Cox regression models were used to determine the associations between HGI quartiles and all-cause mortality with adjustment for cardiovascular risk factors and exercise testing parameters.

Results:

Mean age was 53.5 ± 12.6 years. There were 74,724 (59.1 %) male, 5940 (4.7 %) HF, 21,123 (16.7 %) CAD, and 30,568 (24.2 %) beta-blocker-using patients. During the median follow up of 7.1 years, 9929 (7.9 %) died. Median HGI was 1.93 (interquartile range [IQR] 1.40–2.54) bpm/mmHg. After adjustment for the covariates, lower HGI was independently associated with all-cause mortality in the entire cohort (quartile 1 vs 4, adjusted hazard ratio [95 % confidence interval] 1.33 [IQR 1.21–1.45], p < 0.001), and subgroups of men, women, patients with body mass index <35 kg/m², with and without HF, CAD, and beta-blocker use. The HGI also correlates well with METs in every subgroup.

Conclusions:

The HGI is a strong predictor of long-term mortality independently of traditional cardiovascular risk factors, and exercise performance across patient subgroups.

Blood pressure measurements during treadmill exercise testing and the risk for the future development of atrial fibrillation

Hypertension is a well-established risk factor for the onset and progression of atrial fibrillation (AF). Blood pressure (BP) measurements during routine exercise stress testing (EST) may identify subjects at increased risk for developing AF. We performed a retrospective analysis of treadmill EST carried out using the Bruce protocol in patients aged ≥40 years without a history of AF (n = 17,617; 42% women). BP was measured at rest, peak exercise, and 2-min recovery and analyzed for its association with the risk for developing AF. During a mean follow-up of 7 years, AF was documented in 4.5% of the patients. The incidence rate of AF per 1000 person-years increased with the rise in CHA₂DS₂VASc scores (3.26 for a Score=0 to 19.78 for scores ≥6). In a multivariate analysis, adjusting for risk score components and exercise capacity, systolic BP measurements taken at rest (≥130 vs. ≤110 mmHg), peak exercise (>170 vs. ≤150 mmHg), and recovery (>150 vs. ≤130 mmHg) were associated with an increased risk for AF: the hazard ratios (HRs) were 1.56 (95% CI, 1.30-1.87), 1.21 (1.01-1.45), and 1.33 (1.10-1.62), respectively. Similarly, diastolic BP measurements taken at rest (≥90 vs. <80 mmHg), peak exercise (≥100 vs. <90 mmHg), and recovery (>90 vs. ≤80 mmHg) were associated with an increased risk for AF: the HRs were 1.80 (1.36-2.38), 2.08 (1.28-3.37), and 1.56 (0.81-3.02), respectively. The association of exercise BP with AF was further observed when the BPs were analyzed as continuous variables and in subjects without a baseline diagnosis of hypertension. In conclusion, systolic and diastolic BP taken at the rest, peak exercise and recovery phases of EST may provide independent predictive information regarding future risk for developing AF.

Testes Ergométricos em Pacientes com Anemia Falciforme: Segurança, Viabilidade e Possíveis Implicações no Prognóstico

Fundamento

Pacientes com anemia falciforme (AF) têm risco aumentado de complicações cardiovasculares. O teste ergométrico é usado como marcador de prognóstico em uma série de doenças cardiovasculares. Entretanto, há uma escassez de evidências sobre exercícios em pacientes com AF, especialmente em relação à sua segurança, viabilidade e possível função prognóstica.

Objetivos

Usamos o teste em esteira máximo para determinar a segurança e a viabilidade do teste ergométrico em pacientes com AF. Além disso, os fatores associados à duração do exercício, bem como o impacto das alterações causadas pelo exercício em resultados clínicos, também foram avaliados.

Métodos

113 pacientes com AF que passaram pelo teste ergométrico e por uma avaliação cardiovascular abrangente incluindo um ecocardiograma e os níveis do peptídeo natriurético do tipo B (BNP). O desfecho de longo prazo foi uma combinação de eventos incluindo morte, crises álgicas graves, síndrome torácica aguda ou internações hospitalares por outras complicações associadas â doença falciforme. A análise de regressão de Cox foi realizada para identificar as variáveis associadas ao resultado. Um p valor <0,05 foi considerado estatisticamente significativo.

Resultados

A média de idade foi de 36 ± 12 anos (intervalo, 18-65 anos), e 62 pacientes eram do sexo feminino (52%). A presença de alterações isquêmicas ao esforço e resposta pressórica anormal ao exercício foram detectadas em 17% e 9 % da´população estudada respectivamente. Dois pacientes apresentaram crise álgica com necessidade de internação hospitalar no período de 48 horas da realização do exame. Fatores associados à duração do exercício foram idade, sexo, velocidade máxima de regurgitação tricúspide (RT), e relação E/e’, após a padronização quanto aos marcadores da gravidade da doença. Durante o período médio de acompanhamento de 10,1 meses (variando de 1,2 a 26), 27 pacientes (23%) apresentaram desfechos clínicos adversos. Preditores independentes de eventos adversos foram a concentração de hemoglobina, velocidade do fluxo transmitral tardio (onda A), e a resposta da PA ao exercício.

Conclusões

A realização de testes ergométricos em pacientes com AF, clinicamente estáveis, é viável. A duração do exercício estava associada à função diastólica e a pressão arterial pulmonar. A resposta anormal da PA foi um preditor independente de eventos adversos.

Peak exercise SBP and future risk of cardiovascular disease and mortality

OBJECTIVES

This study aimed to evaluate the risk of all-cause mortality and incident cardiovascular disease associated with peak systolic blood pressure (PeakSBP) at clinical exercise testing.

METHODS

Data from 10 096 clinical exercise tests (54% men, age 18-85 years) was cross-linked with outcome data from national registries. PeakSBP was compared with recently published reference percentiles as well as expressed as percentage predicted PeakSBP using reference equations.Natural cubic spline modelling and Cox regression were used to analyse data stratified by sex and baseline cardiovascular risk profile.

RESULTS

Median [IQR] follow-up times were 7.9 [5.7] years (all-cause mortality) and 5.6 [5.9] years (incident cardiovascular disease), respectively. The adjusted risk of all-cause mortality [hazard ratio, 95% confidence interval (95% CI)] for individuals with PeakSBP below the 10th percentile was 2.00 (1.59-2.52) in men and 2.60 (1.97-3.44) in women, compared with individuals within the 10th--90th percentile. The corresponding risk for incident cardiovascular disease was 1.55 (1.28-1.89, men) and 1.34 (1.05-1.71, women). For males in the upper 90th percentile, compared with individuals within the 10th--90th percentile, the adjusted risks of all-cause death and incident cardiovascular disease were 0.35 (0.22-0.54) and 0.72 (0.57-0.92), respectively, while not statistically significant in women. Spline modelling revealed a continuous increase in risk with PeakSBP values less than 100% of predicted in both sexes, with no increase in risk more than 100% of predicted.

CONCLUSION

Low, but not high, PeakSBP was associated with an increased risk of mortality and future cardiovascular disease. Using reference standards for PeakSBP could facilitate clinical risk stratification across patients of varying sex, age and exercise capacity.

Blood pressure response during treadmill exercise testing and the risk for future cardiovascular events and new-onset hypertension

OBJECTIVE

The physiologic response to exercise may provide valuable prognostic information. We investigated the association of blood pressure (BP) measurements during exercise stress testing (EST) with long-term risk of myocardial infarction, stroke or death (major adverse cardiovascular event, MACE), as well as the development of new-onset hypertension.

METHODS

A retrospective analysis of treadmill ESTs (years 2005-2019) performed by the Bruce protocol in patients aged 35-75 years without a history of cardiovascular disease (n = 14 792; 48% women). BP was documented at rest, submaximal exercise (Bruce stage-2), peak exercise and recovery (2 min). Association of SBP measures with study outcomes during median follow-up of 6.5 years was investigated.

RESULTS

Highest vs. lowest SBP quartile at rest (≥140 vs. <120 mmHg), submaximal-exercise (≥170 vs. <130 mmHg), peak-exercise (≥180 vs. ≤145 mmHg) and recovery (≥160 vs. <130 mmHg) was associated with an increase in the adjusted hazard ratio and 95% confidence interval (CI) for MACE: 1.53 (1.23-1.88), 1.33 (1.01-1.76), 1.30 (1.05-1.61), 1.35 (1.09-1.68), respectively. The association between SBP at submaximal exercise and recovery with MACE displayed a J-shaped pattern. Among nonhypertensive patients (n = 8529), excessive SBP response to peak exercise (≥190 mmHg in women and ≥210 mmHg in men) was an independent predictor of hypertension [hazard ratio (95% CI)]: 1.87 (1.41-2.48), as were SBPs during submaximal exercise [>160 vs. ≤130 mmHg: 2.44 (1.97-3.03)] and recovery [≥140 vs. ≤120 mmHg: 1.65 (1.37-1.98)].

CONCLUSION

BP measurement during rest, exercise and recovery phases of EST provides incremental prognostic information regarding long-term risk for cardiovascular events and the probability for developing hypertension.

Exercise blood pressure and cardiovascular disease risk: a systematic review and meta-analysis of cross-sectional studies

BACKGROUND

A hypertensive response to exercise (HRE) is associated with cardiovascular disease and high blood pressure (BP). A poor cardiovascular risk factor profile may underlie these associations, although this has not been systematically elucidated. Via systematic review and meta-analysis, we aimed to assess the relationship between exercise BP and cardiovascular risk factors, and determine if cardiovascular risk is higher in those with an HRE vs. no-HRE across different study populations (including those with/without high BP at rest).

METHODS

Three online databases were searched for cross-sectional studies reporting data on exercise BP, an HRE and cardiovascular risk factors (including arterial structure, lipid, metabolic, inflammatory and kidney function markers). Random-effects meta-analyses and meta-regression were used to calculate pooled correlations between exercise BP and each risk factor and pooled mean differences between those with/without an HRE.

RESULTS

Thirty-eight studies (38 295 participants, aged 50 ± 3years; 78% male) were included. Exercise SBP was associated with arterial, lipid and kidney function risk markers (P < 0.05). Those with an HRE had greater aortic stiffness (+0.80 ± 0.35 m/s), total (+0.14 ± 0.03 mmol/l) and low-density lipoprotein (+0.12 ± 0.03 mmol/l) cholesterol, triglycerides (+0.24 ± 0.04 mmol/l), glucose (+0.15 ± 0.05 mmol/l), white blood cell count (+0.49 ± 0.16 mmol/l) and albumin-to-creatinine ratio (standardized mean difference: +0.97 ± 0.34), and lower flow-mediated dilation (-4.13 ± 1.02%) and high-density lipoprotein cholesterol (-0.04 ± 0.01 mmol/l) vs. those with no-HRE (P < 0.05 all). Results were broadly similar across study populations.

CONCLUSION

Exercise SBP is associated with multiple cardiovascular risk factors, which appear worse in those with an HRE vs. no-HRE. As results were similar across population groups, an HRE should be considered an important indicator of cardiovascular risk.

Acute cardiovascular responses of wildland firefighters to working at prescribed burn

Wildland firefighters at prescribed burns are exposed to elevated levels of wildland fire smoke (WFS) while performing physically demanding tasks. WFS exposure has been linked to increases in hospital and emergency admissions for cardiovascular disorders in the general population. However, knowledge about the cardiovascular effect of occupational WFS exposure among wildland firefighters is limited. To provide a better understanding of the effect of this exposure scenario on acute hemodynamic responses, resting systolic/diastolic blood pressure (SBP/DBP) and heart rate (HR) of wildland firefighters were measured before (pre-shift), after (post-shift), and the morning (next morning) immediately following prescribed burn shifts (burn days) and regular work shifts (non-burn days). A total of 38 firefighters (34 males and 4 females) participated in this study and resting BP and HR were recorded on 9 burn days and 7 non-burn days. On burn days, HR significantly increased from pre-to post-shift (13.25 bpm, 95% CI: 7.47 to 19.02 bpm) while SBP significantly decreased in the morning following the prescribed burns compared to pre-shift (-6.25 mmHg, 95% CI: -12.30 to -0.20 mmHg). However, this was due to the decrease of SBP in the firefighters who were hypertensive (-8.46 mmHg, 95% CI: -16.08 to -0.84 mmHg). Significant cross-shift reductions (post-shift/next morning vs. pre-shift) were observed in SBP on burn days compared to non-burn days (-7.01 mmHg, 95% CI: -10.94 to -3.09 mmHg and -8.64 mmHg, 95% CI: -13.81 to -3.47 mmHg, respectively). A significant reduction on burn days was also observed from pre-shift to the following morning for HR compared to non-burn days (-7.28 bpm, 95% CI: -13.50 to -1.06 bpm) while HR significantly increased in pre-to post-shift on burn days compared to non-burn days (10.61 bpm, 95% CI: 5.05 to 16.17 bpm). The decreased BP observed in wildland firefighters might be due to a high level of carbon monoxide exposure and exercise-induced hypotension. The increase in HR immediately after prescribed burns might be attributable to WFS exposure and physical exertion in prescribed burn shifts. The results suggest that wildland firefighting exposure might cause a distinct hemodynamic response, including SBP reduction and HR increment, especially for those who have pre-existing hypertension.

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.

Physical Activity and Cumulative Long-Term Care Cost among Older Japanese Adults: A Prospective Study in JAGES

This study aimed to determine the impact of physical activity on the cumulative cost of long-term care insurance (LTCI) services in a cohort of community-dwelling people (65 years and older) in Japan. Using cohort data from the Japan Gerontological Evaluation Study (JAGES) on those who were functionally independent as of 2010/11, we examined differences in the cumulative cost of LTCI services by physical activity. We followed 38,875 participants with LTCI service costs for 59 months. Physical activity was assessed by the frequency of going out and time spent walking. We adopted a generalized linear model with gamma distribution and log-link function, and a classical linear regression with multiple imputation. The cumulative LTCI costs significantly decreased with the frequency of going out and the time spent walking after adjustment for baseline covariates. LTCI's cumulative cost for those who went out once a week or less was USD 600 higher than those who went out almost daily. Furthermore, costs for those who walked for less than 30 min were USD 900 higher than those who walked for more than 60 min. Physical activity among older individuals can reduce LTCI costs, which could provide a rationale for expenditure intervention programs that promote physical activity.

Peak Systolic Blood Pressure During the Exercise Test: Reference Values by Sex and Age and Association With Mortality

[Figure: see text].

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Blood Pressure Screening by Outpatient Physical Therapists: A Call to Action and Clinical Recommendations

Hypertension (HTN) is among the leading global preventable risk factors for cardiovascular disease and premature mortality. Early detection and effective management of HTN have demonstrated significant reductions in mortality, morbidity rate, and health care costs. Furthermore, screening for HTN by nonphysician health care providers improves detection rates and medical management. As physical therapist practice advances to a more independent care model, physical therapists may serve as the first point of contact into the health care system, thereby necessitating a need for routine blood pressure (BP) monitoring. This is especially relevant in the outpatient physical therapist practice setting, where there is evidence for elevated BP measures among patients, yet omission of routine screening in this setting is well documented. Leading physical therapy professional organizations include statements in their guidelines that suggest that physical therapists have a duty to provide a standard of care that protects the safety and optimizes the overall health of patients under their care. Therefore, it is imperative not only that physical therapists include BP examination into routine practice protocols but that the knowledge and skills to accurately measure and interpret BP at rest and during exercise be integrated into the standard of care. The authors suggest that the profession of physical therapy proactively embrace their potential to address the national and worldwide HTN epidemic through routine assessment of BP, appropriate referral for elevated BP measures, and exploration of HTN management by physical therapists.

Workload-indexed blood pressure response to a maximum exercise test among professional indoor athletes

BACKGROUND

Exercise testing is performed regularly in professional athletes. However, the blood pressure response (BPR) to exercise is rarely investigated in this cohort, and normative upper thresholds are lacking. Recently, a workload-indexed BPR (increase in systolic blood pressure per increase in metabolic equivalent of task (SBP/MET slope)) was evaluated in a general population and was compared with mortality. We sought to evaluate the SBP/MET slope in professional athletes and compare it with performance.

DESIGN

This was a cross-sectional study.

METHODS

A total of 142 male professional indoor athletes (age 26 ± 5 years) were examined. Blood pressure was measured at rest and during a standardized, graded cycle ergometer test. We assessed the BPR during exercise, the workload, and the metabolic equivalent of task (MET). Athletes were divided into groups according to their SBP/MET slope quartiles (I <4.3; II 4.3-6.2; III >6.2-9; IV >9 mmHg/MET) and compared regarding systolic BP (sBP) and workload achieved.

RESULTS

Athletes in group I (n = 42) had the lowest maximum sBP (180 ± 13 mmHg) but achieved the highest relative workload (4.2 ± 1 W/kg). With increasing SBP/MET slope, the maximum sBP increased (II (n = 56): 195 ± 15 mmHg; III (n = 44): 216 ± 16 mmHg) and the workload achieved decreased (II: 3.9 ± 0.7 W/kg; III: 3.3 ± 0.5 W/kg). The differences in sBP between these groups were significant (p < 0.001). None of the athletes were assigned to group IV (>9 mmHg/MET).

CONCLUSION

Athletes in the lowest SBP/MET slope quartile displayed the lowest maximum sBP but achieved a higher workload than athletes classified into the other SBP/MET slope groups. This simple, novel metric might help to distinguish a normal from an exaggerated BPR to exercise, to identify athletes at risk of developing hypertension.

Combination of low blood pressure response, low exercise capacity and slow heart rate recovery during an exercise test significantly increases mortality risk

Aims: We investigated the combination of low systolic blood pressure (SBP) response, low exercise capacity (EC) and slow heart rate recovery (HRR) during an exercise test in mortality prediction.Patients and methods: Our population consisted of 3456 patients from the Finnish Cardiovascular Study. A failure of SBP to increase >42 mmHg was defined as a low response. Low EC was defined as  < 8 metabolic equivalents. 1-minute HRR ≤18 bpm from maximum was defined as slow HRR.Results: During a median follow up of 10.0 years, 537 participants died. Reduced SBP response, low EC and slow HRR were independent predictors of all-cause and CV mortality (p < .001 for all). Patients with reduced SBP response, low EC and slow HRR had a very high mortality rate of 42.1% during follow up compared to only 4.5% of the patients without any of these risk factors. The hazard ratios for all-cause mortality in patients with one, two or three of the studied risk factors were 3.2, 6.0, and 10.6, respectively (p < .001 for all).Conclusion: The combination of reduced SBP response, low exercise capacity, and reduced HRR in an exercise test is associated with very high mortality and can be used in risk stratification.Key messagesThe combination of low blood pressure response, low exercise capacity and slow heart rate recovery in an exercise test is able to identify a group of patients in a very high mortality risk.These parameters are easily derived from an exercise test.All parameters are commonly available in clinical practice.

Impaired baroreflex sensitivity, carotid stiffness, and exaggerated exercise blood pressure: a community-based analysis from the Paris Prospective Study III

Aims

People with exaggerated exercise blood pressure (BP) have adverse cardiovascular outcomes. Mechanisms are unknown but could be explained through impaired neural baroreflex sensitivity (BRS) and/or large artery stiffness. This study aimed to determine the associations of carotid BRS and carotid stiffness with exaggerated exercise BP.

Methods and results

Blood pressure was recorded at rest and following an exercise step-test among 8976 adults aged 50 to 75 years from the Paris Prospective Study III. Resting carotid BRS (low frequency gain, from carotid distension rate, and heart rate) and stiffness were measured by high-precision echotracking. A systolic BP threshold of ≥ 150 mmHg defined exaggerated exercise BP and ≥140/90 mmHg defined resting hypertension (±antihypertensive treatment). Participants with exaggerated exercise BP had significantly lower BRS [median (Q1; Q3) 0.10 (0.06; 0.16) vs. 0.12 (0.08; 0.19) (ms2/mm) 2×108; P < 0.001] but higher stiffness [mean ± standard deviation (SD); 7.34 ± 1.37 vs. 6.76 ± 1.25 m/s; P < 0.001) compared to those with non-exaggerated exercise BP. However, only lower BRS (per 1SD decrement) was associated with exaggerated exercise BP among people without hypertension at rest {specifically among those with optimal BP; odds ratio (OR) 1.16 [95% confidence intervals (95% CI) 1.01; 1.33], P = 0.04 and high-normal BP; OR, 1.19 (95% CI 1.07; 1.32), P = 0.001} after adjustment for age, sex, body mass index, smoking, alcohol, total cholesterol, high-density lipoprotein cholesterol, resting heart rate, and antihypertensive medications.

Conclusion

Impaired BRS, but not carotid stiffness, is independently associated with exaggerated exercise BP even among those with well controlled resting BP. This indicates a potential pathway from depressed neural baroreflex function to abnormal exercise BP and clinical outcomes.

Exercise and sport science australia position stand update on exercise and hypertension

Hypertension is the most common circulatory system condition, accounting for >40% of the cardiovascular disease total burden. One-third of Australians aged over 18 years have hypertension and in 68% of these it is uncontrolled. Australian data show hypertension accounts for 6% of general practitioner (GP) consults. Recent evidence has confirmed exercise is an effective adjunct therapy for hypertension management and the objective of this document is to provide a contemporary, evidence-based guide for optimal delivery of an exercise programme for blood pressure management. This work is an update to the 2009 Exercise and Sport Science Australia (ESSA) position stand. In most cases, the first line treatment to reduce BP is initiation of lifestyle changes, of which regular aerobic exercise is a principal component. Aerobic and resistance activities remain the cornerstone of exercise-based management of blood pressure, but recent work has uncovered variations on traditional delivery of exercise, such as high intensity interval training (HIIT) and a new exercise modality, isometric resistance training (IRT) may offer alternative management regimens. Exercise Physiologists, as well as other health care professionals, play an important role in helping to achieve BP control in patients with hypertension by reinforcing healthy lifestyle habits and prescribing appropriate exercise.

Genomics of Cardiovascular Measures of Autonomic Tone

The autonomic nervous system exerts broad control over the involuntary functions of the human body through complex equilibrium between sympathetic and parasympathetic tone. Imbalance in this equilibrium is associated with a multitude of cardiovascular outcomes, including mortality. The cardiovascular static state of this equilibrium can be quantified using physiological parameters such as heart rate (HR), blood pressure, and by spectral analysis of HR variability. Here, we review the current state of knowledge of the genetic background of cardiovascular measurements of autonomic tone. For most parameters of autonomic tone, a large portion of variability is explained by genetic heritability. Many of the static parameters of autonomic tone have also been studied through candidate-gene approach, yielding some insight into how genotypes of adrenergic receptors affect variables such as HR. Genome-wide approaches in large cohorts similarly exist for static variables such as HR and blood pressure but less is known about the genetic background of the dynamic and more specific measurements, such as HR variability. Furthermore, because most autonomic measures are likely polygenic, pathway analyses and modeling of polygenic effects are critical. Future work will hopefully explain the control of autonomic tone and guide individualized therapeutic interventions.

Cardiorespiratory Fitness and Cardiovascular Disease Prevention: an Update

PURPOSE OF REVIEW

Cardiovascular diseases account for nearly one third of all deaths globally. Improving exercise capacity and cardiorespiratory fitness (CRF) has been an important target to reduce cardiovascular events. In addition, the American Heart Association defined decreased physical activity as the fourth risk factor for coronary artery disease. Multiple large cohort studies have evaluated the impact of CRF on outcomes. In this review, we will discuss the role of CRF in reducing cardiovascular morbidity and mortality.

RECENT FINDINGS

Recent data suggest that CRF has an important role in reducing not only cardiovascular and all-cause mortality, but also incident myocardial infarction, hypertension, diabetes, atrial fibrillation, heart failure, and stroke. Most recently, its role in cancer prevention started to emerge. CRF protective effects have also been seen in patients with prior comorbidities like prior coronary artery disease, heart failure, depression, end-stage renal disease, and stroke. The prognostic value of CRF has been demonstrated in various patient populations and cardiovascular conditions. Higher CRF is associated with improved survival and decreased incidence of cardiovascular diseases (CVD) and other comorbidities including hypertension, diabetes, heart failure, and atrial fibrillation.

Peak circulatory power is a strong prognostic factor in patients with idiopathic pulmonary arterial hypertension

BACKGROUND

Studies have shown that peak circulatory power (peak CircP; peak oxygen uptake × peak systolic blood pressure) is a variable predictor of prognosis in patients with left heart failure. It remains unknown whether peak CircP also predicts outcome in patients with idiopathic pulmonary arterial hypertension (IPAH).

METHODS

Patients with newly diagnosed IPAH who underwent symptom-limited cardiopulmonary exercise testing (CPET) from 1 January 2011 to 1 January 2014 in Fuwai Hospital were prospectively enrolled and followed for up to 66 months for cardiac events (mortality and lung transplantation).

RESULTS

One hundred forty patients with IPAH (104 female, mean age: 33 ± 11 years) were studied. During follow-up (mean: 42 ± 14 months), 24 patients died and 1 patient underwent lung transplantation. In the univariate analysis, peak oxygen uptake(VO₂), oxygen uptake at anaerobic threshold, ventilation (VE)/carbon dioxide output (VCO₂) slope, end-tidal partial pressure of carbon dioxide at anaerobic threshold, peak systolic blood pressure (SBP), the change of SBP, the change of heart rate, peak work rate, peak CircP, pulmonary vascular resistance, cardiac index and World Health Organization functional class were predictive of cardiac events (all P < .05).In the multivariate analysis, Peak CircP in the fourth model had the highest significance compared with peak VO₂ and VE/VCO₂ slope in the second and third model (chi-square = 5.26, P < .02, HR: 0.99, 95% CI: 0.99 to 1.00).

CONCLUSIONS

Peak CircP, better than peak VO₂ and VE/VCO₂slope, was a strong predictor of cardiac events among exercise parameters in patients with IPAH.

Peak Blood Pressure Responses During Maximum Cardiopulmonary Exercise Testing: Reference Standards From FRIEND (Fitness Registry and the Importance of Exercise: A National Database)

The objective of this study is to expand on previous efforts in establishing normative standards of exercising blood pressure (BP) at maximal physical exertion derived from treadmill cardiopulmonary exercise testing in the United States. Four experienced laboratories in the United States with established quality control procedures contributed data from September 1, 1986, to February 1, 2015. A total of 2917 maximal (peak respiratory exchange ratio ≥1.00) treadmill cardiopulmonary exercise testing responses from apparently healthy men and women (aged 20-79 years) without cardiovascular disease were submitted to FRIEND (Fitness Registry and the Importance of Exercise: A National Database). Percentiles of maximal systolic and diastolic BP were determined for each decade. Our results show a continued increase in peak systolic BP with age in both men and women to the sixth decade, followed by a plateau between the sixth and seventh decades. However, the trajectory of peak diastolic BP with age is different between men and women. Men showed an increase in peak systolic BP until the fifth decade, which plateaued by the seventh decade. In contrast, women showed a continued increase in peak diastolic BP across each decade. Existing reference data for exercising BP have not been updated for >20 years. Normative peak exercising BP values from FRIEND can be used to provide a more current representation of maximal BP during exercise testing in the US population.

DNA methylation signatures in peripheral blood mononuclear cells from a lifestyle intervention for women at midlife: a pilot randomized controlled trial

Physical activity confers many health benefits, but the underlying mechanisms require further exploration. In this pilot randomized controlled trial we tested the association between longitudinal measures of DNA methylation and changes in objective measures, including physical activity, weight loss, and C-reactive protein levels in community-dwelling women aged 55 to 70 years. We assessed DNA methylation from 20 healthy postmenopausal women, who did not have a mobility disability and allocated them to a group-based intervention, Everyday Activity Supports You, or a control group (monthly group-based health-related education sessions). The original randomized controlled trial was 6 months in duration and consisted of nine 2-h sessions that focused on reducing sedentary behaviour for the intervention group, or six 1-h sessions that focused on other topics for the control group. We collected peripheral blood mononuclear cells, both at baseline and 6 months later. Samples were processed using the Illumina 450k Methylation array to quantify DNA methylation at >485 000 CpG sites in the genome. There were no significant associations between DNA methylation and physical activity, but we did observe alterations at epigenetic modifications that correlated with change in percent body weight over a 6-month period at 12 genomic loci, 2 of which were located near the previously reported weight-associated genes RUNX3 and NAMPT. We also generated a potential epigenetic predictor of weight loss using baseline DNA methylation at 5 CpG sites. These exploratory findings suggest a potential biological link between body weight changes and epigenetic processes.

Survival and prognostic factors in hypertrophic cardiomyopathy: a meta-analysis

Hypertrophic cardiomyopathy (HCM) is a clinically and genetically heterogeneous disorder but data on survival rates are still conflicting and have not so far been quantitatively reviewed. The aim of this study is to conduct a meta-analysis of cohort studies to assess pooled survival rates and prognostic factors for survival in patients with HCM. Nineteen studies were included representing 12,146 HCM patients. The pooled 1-, 3-, 5- and 10-year survival rates were 98.0%, 94.3%, 82.2% and 75.0%, respectively. Among patients with HCM, age, NYHA functional class, family history of sudden death (FHSD), syncope, atrial fibrillation, non-sustained ventricular tachycardia (nsVT), maximum left ventricular wall thickness and obstruction were significant prognostic factors for cardiovascular death. For sudden cardiac death, FHSD, nsVT, and obstruction showed significant predictive values. Moreover, estimation of population attributable risk (PAR) suggested that nsVT was the strongest predictor for cardiovascular death (13.02%, 95% CI 3.60–25.91%), while left ventricular outflow tract obstruction/mid-ventricular obstruction (LVO/MVO) was the strongest predictor for all-cause death and sudden cardiac death (10.09%, 95% CI 4.72–20.42% and 16.44%, 95% CI 7.45–31.55%, respectively). These risk factors may thus be useful for identifying HCM patients who might benefit from early diagnosis and therapeutic interventions.

Exercise prevents development of autonomic dysregulation and hyperalgesia in a mouse model of chronic muscle pain

Chronic musculoskeletal pain (CMP) conditions, like fibromyalgia, are associated with widespread pain and alterations in autonomic functions. Regular physical activity prevents the development of CMP and can reduce autonomic dysfunction. We tested if there were alterations in autonomic function of sedentary mice with CMP, and whether exercise reduced the autonomic dysfunction and pain induced by CMP. Chronic musculoskeletal pain was induced by 2 intramuscular injections of pH 5.0 in combination with a single fatiguing exercise task. A running wheel was placed into cages so that the mouse had free access to it for either 5 days or 8 weeks (exercise groups) and these animals were compared to sedentary mice without running wheels. Autonomic function and nociceptive withdrawal thresholds of the paw and muscle were assessed before and after induction of CMP in exercised and sedentary mice. In sedentary mice, we show decreased baroreflex sensitivity, increased blood pressure variability, decreased heart rate variability, and decreased withdrawal thresholds of the paw and muscle 24 hours after induction of CMP. There were no sex differences after induction of the CMP in any outcome measure. We further show that both 5 days and 8 weeks of physical activity prevent the development of autonomic dysfunction and decreases in withdrawal threshold induced by CMP. Thus, this study uniquely shows the development of autonomic dysfunction in animals with chronic muscle hyperalgesia, which can be prevented with as little as 5 days of physical activity, and suggest that physical activity may prevent the development of pain and autonomic dysfunction in people with CMP.

Relation of Risk of Atrial Fibrillation With Systolic Blood Pressure Response During Exercise Stress Testing (from the Henry Ford ExercIse Testing Project)

Decreases in systolic blood pressure during exercise may predispose to arrhythmias such as atrial fibrillation (AF) because of underlying abnormal autonomic tone. We examined the association between systolic blood pressure response and incident AF in 57,442 (mean age 54 ± 13 years, 47% women, and 29% black) patients free of baseline AF who underwent exercise treadmill stress testing from the Henry Ford ExercIse Testing project. Exercise systolic blood pressure response was examined as a categorical variable across clinically relevant categories (>20 mm Hg: referent; 1 to 20 mm Hg, and ≤0 mm Hg) and per 1-SD decrease. Cox regression, adjusting for demographics, cardiovascular risk factors, medications, history of coronary heart disease, history of heart failure, and metabolic equivalent of task achieved, was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between systolic blood pressure response and incident AF. Over a median follow-up of 5.0 years, a total of 3,381 cases (5.9%) of AF were identified. An increased risk of AF was observed with decreasing systolic blood pressure response (>20 mm Hg: HR 1.0, referent; 1 to 20 mm Hg: HR 1.09, 95% CI 0.99, 1.20; ≤0 mm Hg: HR 1.22, 95% CI 1.06 to 1.40). Similar results were obtained per 1-SD decrease in systolic blood pressure response (HR 1.08, 95% CI 1.04 to 1.12). The results were consistent when stratified by age, sex, race, hypertension, and coronary heart disease. In conclusion, our results suggest that a decreased systolic blood pressure response during exercise may identify subjects who are at risk for developing AF.