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

Abstract

ObjectivesThe 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).MethodsWe 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.ResultsA 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.ConclusionsA 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.

Blood Pressure Responses During Exercise: Physiological Correlates and Clinical Implications

“…Second, ≈25% of community-dwelling individuals in our study exhibited peak SBP values above existing clinical thresholds, but some of these individuals achieved high peak SBP due primarily to greater cardiac-peripheral performance. These findings in relation to cross-sectional physiological measures are therefore in concert with other studies showing that high peak SBP may not be a good predictor of adverse outcomes at the population level, 42 raising the prospect of using CPET (or imaging-based measures of stroke volume/cardiac performance) to clarify the physiological determinants and relevance of a high peak exercise SBP. Third, we observed that BP measures that account for workload (eg, BP at a fixed workload, or the SBP/W slope) were directly related with higher arterial stiffness and lower cardiac-peripheral performance.…”

Peak Circulatory Power during Maximal Cardiopulmonary Exercise Testing: Reference Standards from the FRIEND Registry

“…Considered independently, the meaning of peak SBP values during exercise testing remains uncertain with studies finding both an increased (28,29) and a decreased (30,31) risk of mortality with elevated SBP during exercise. Although the SBP values of 210 and 190 mm Hg for males and females, respectively, are generally recognized as the upper thresholds of healthy SBP responses to exercise (32), Hedman et al (33) recently found that low, not high, peak SBP, in reference to established age- and sex-specific peak SBP reference values, was associated with an increased risk of all-cause mortality in adult males. Therefore, an elevated but not overly exaggerated increase in SBP at peak exercise may reflect healthy systolic cardiac function and the integrity of the surrounding vasculature.…”

Reply to ‘Blood pressure during moderate or maximal exercise: hardly two sides of the same coin’

“…Although our recent publications evaluated the outcome related to peak SBP [2,4], we do not by any means reject the clinical value of using submaximal SBP to determine the risk of adverse outcome in patients undergoing exercise testing. In contrast, submaximal SBP has the advantage of indirectly considering work rate, especially if the submaxi-mal work rate is standardized [5].…”