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

Abstract

We sought to update norms for peak systolic blood pressure (SBP) on the graded exercise test and examine its prognostic value in patients without baseline cardiovascular disease. Mayo graded exercise test data (1993–2010) were reviewed for nonimaging tests using Bruce protocol, selecting Minnesota residents 30 to 79 years without baseline cardiovascular disease. We formed a pure cohort of patients without factors significantly affecting peak SBP to determine peak SBP percentile norms by age and sex. Then we divided the full cohort of patients into 5 groups based on peak SBP percentiles: low (<10th), borderline low (10th–25th), referent (25th–75th), borderline high (75th–90th), and high (>90th). The relationship between peak SBP and mortality was tested using Cox regression adjusting for age, sex, and comorbidities affecting peak SBP or mortality. We identified 20 760 eligible patients with 7313 females (35%) and mean age 51.5±10.7 years. Our pure cohort included 7810 patients. Over 12.5±5.0 years follow-up, there were 1582 deaths, including 541 cardiovascular deaths. In the fully adjusted model, low-peak SBP was associated with increased total mortality (heart rate, 1.41 [1.19–1.66], P <0.0001) and cardiovascular mortality (heart rate, 1.54 [1.16–2.03], P =0.001), while borderline low-peak SBP was associated with increased cardiovascular mortality only (heart rate, 1.36 [1.02–1.81], P =0.027). High peak SBP was associated with increased total mortality only in the age-sex adjusted model (heart rate, 1.18 [1.02–1.36], P =0.026), not after full adjustment. We conclude that low exercise peak SBP is an independent predictor of higher total and cardiovascular mortality.

Peak exercise SBP and future risk of cardiovascular disease and mortality

“…Theoretically, examining the SBP response in relation to well defined reference values rather than using (at the most) sex-specific thresholds would be a more appropriate approach, enabling comparisons across studies and between individuals of, for example, different age. Two recent studies have used reference percentiles to explore the risk of all-cause death associated with peak SBP measured during treadmill exercise in two different U.S. cohorts [18,24]. As discussed, the results are similar to that in the current study, which is the first to study peak SBP from bicycle exercise testing and to use reference equations considering workload.…”

Systolic Blood Pressure During Exercise Testing: Where the Valley Means More Than the Peak

“…In this issue of Hypertension , Assaf et al 3 studied the association of another variable measured during the ETT—peak systolic blood pressure (SBP). Results of previous studies are mixed.…”

“…In contrast, others demonstrate no association. 4 Assaf et al 3 included 20 760 adults aged 30 to 79 years without preexisting cardiovascular disease referred for a clinically indicated ETT at the Mayo Clinic from 1993 to 2010. Patients’ vital status was determined with the National Death Index after a mean follow-up of 12.5 years.…”

“…Assaf et al 3 made 3 vital contributions to the literature with their investigation. 5 First, they derived age- and sex-based cutoff percentiles for peak SBP.…”

“…The peak SBPs obtained in the current report ranged 7 to 14 mm Hg lower than 2 previously published reports, one from a registry of 2917 patients who underwent cardiopulmonary exercise testing before starting an exercise program the other from 10 269 adults referred for clinically indicated tests. 5,6 Assaf et al 3 included patients taking BP (blood pressure)-lowering medications, whereas they were excluded from one of the other studies. 6…”