Article

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

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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.

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... Physicians faced with interpreting the SBP response during exercise testing are up for a difficult task, as there is currently no consensus on the normal SBP response to exercise [17], and contemporary reference values have been lacking until recently [11,12,18]. As thoroughly summarized by others [4,5], there is a large variety of criteria to define an exaggerated SBP response to exercise and previous prognostic studies used different, arbitrary cut-offs for peak SBP [7][8][9][10]. ...
... 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. ...
... (2021) found a 41% increase in risk of all-cause mortality and a 54% increase in risk of cardiovascular mortality in individuals with a peak SBP in the lowest 10th percentile derived in a healthy reference population (referent: 25th-75th percentile), after adjustment for age, sex and baseline risk factors [18]. Similarly, Hedman et al. [24] found an increased risk of all-cause mortality in male U.S. Veterans presenting with a peak SBP falling into the 10th percentile of a different reference population (referent: 10th-90th percentile) after adjusting for age, SBP at rest and exercise capacity. ...
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Background: Functional aerobic capacity (FAC) determined by treadmill exercise testing (TMET) is associated with cardiovascular (CV) disease mortality independent of traditional CV risk factors and is a potentially underutilized tool. The purpose of this study was to determine added prognostic value of reduced FAC and other exercise test abnormalities beyond CV risk factors for predicting total and CV mortality. Methods: The TMET database was queried for Minnesota patients (≥30 years) without baseline CV disease from September 21, 1993, through December 20, 2010. Risk factors and exercise abnormalities including low FAC (<80% predicted), abnormal heart rate recovery (<13 bpm), and abnormal electrocardiogram (ST depression ≥1 mm regardless of baseline) were extracted. Mortality data were obtained through February 2016. Patients were divided into 9 groups by abnormality number (0, 1, or ≥2) and risk factors (0, 1, or ≥2). Cox regression was used to determine mortality risk according to exercise abnormalities/CV risk factors, adjusted for age and sex. Results: 19,551 patients met inclusion criteria; 1271 (6.5%) died over 12.4 ± 5.0 years' follow-up (405 [32%] CV deaths). Exercise abnormalities significantly modified risk for every number of CV risk factors. Hazard ratios (95% CI) for total mortality (0 vs ≥2 abnormalities) were 2.4 (1.9-2.9; P < .001) for 0 CV risk factors; 2.7 (2.2-3.3; P < .001), 1 risk factor; and 6.1 (4.8-7.7; P < .001), ≥2 risk factors. Similar results were noted for CV disease mortality. Conclusions: Exercise test abnormalities strongly predict mortality beyond traditional CV risk factors. Our results indicate that TMET should be considered for CV risk assessment.
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Previous work has shown a gender difference in the normal cardiac response to exercise. Men had significantly higher absolute systolic blood pressure responses at 50%, 75%, and 100% peak heart rate on all modalities (p less than 0.05). This difference is absent when systolic blood pressure is adjusted for body surface area, is reduced when adjusted for body weights, and is reversed when systolic blood pressure is adjusted for lean body mass. The influence of gender on the systolic blood pressure response to dynamic exercise was independent of exercise modality. Men had a higher systolic blood pressure in spite of the fact that they had similar sympathetic nervous system response as indicated by urinary norepinephrine excretion. Gender differences in systolic blood pressure responses were altered when adjusted for body weight, body surface area, and lean body mass.
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A network of 15 maximal exercise testing facilities in four teaching hospitals, 10 private offices and clinics and an industrial medical department was organized in July 1971 to study prospectively the antecedents of myocardial infarction and sudden cardiac death. Within 18 months 2,332 men were tested: 1,275 healthy “normal” subjects, 97 with prior myocardial infarction, 306 with angina pectoris, 193 with hypertension and 461 with various mutually exclusive combinations of these diagnoses; among these clinical groups were five patients who had had a prior episode of ventricular fibrillation. Historical, physical and laboratory data were recorded on self-teaching printed forms, with normal, borderline and abnormal responses arranged in three columns. Classification with respect to “unlikely,” “questionable” or “likely” risk of future cardiac events was assessed from the highest tally of items in these columns. Analysis showed computer-averaged S-T segment responses were more consistent and reliable predictors than visual interpretations.Cardiac manifestations in healthy men varled with age and risk assessment, and in patients with cardiovascular disease varied with diagnosis and natural history of disease. Many significant differences provided insights into mechanisms of impaired cardiac function in relation to type of clinical disease. Testing was responsible for one postexertional cardiac arrest. Recovery was effected promptly by defibrillation; there was no mortality.
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The early detection of hypertension is of foremost concern. It may be that individuals who are normotensive at rest but who show an exaggerated blood pressure (BP) response to exercise are at greater risk of developing hypertension in the future. From exercise tests, a group (ER) of healthy young males who were normotensive at rest (BP less than or equal to 140/90) but showed an exaggerated BP response to exercise (systolic BP greater than or equal to 200 mm Hg and/or diastolic BP 10 mm Hg to greater than 90 mm Hg) were selected. A control group (NR) with exercise BP values less than these were matched for age, weight/height, skinfold thickness, resting BP less than or equal to 140/90, resting heart rate, aerobic fitness level, physical activity, smoking history, and family history of hypertension. After a follow-up period of 5.8 years (range 3 to 14 years) eight of the subjects from the ER group were found to be hypertensive, whereas none of the NR group were hypertensive. Stepwise multivariate regression showed the exercise blood pressure to be the best predictor of future blood pressure of the parameters reviewed in this study. Exaggerated BP response to exercise may serve as an additional risk marker for hypertension.
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Early detection of persons at risk for hypertension (HT) has the obvious benefit of providing more time for applying measures to prevent or delay the onset of resting HT. Maximum systolic and diastolic blood pressure during an initial Balke treadmill test were used to predict subsequent resting HT over an average period of 32 months. Subjects were 3,395 men and 425 women, between the ages of 25 and 65, in a non-hospital population. It was found that one of every eight patients with normal resting blood pressure (RBP) was actually in a higher risk category with over twice the risk of subsequently developing resting HT. For subjects with normal RBP (<) but high exercise blood pressure (EBP) (⩾), the relative risk (RR) of subsequent resting HT was 2.28 when compared with those who were normal for both RBP and EBP. For women, RR was 3.33; for men it was 2.17. When examined according to various cardiovascular risk factors, subsets of the data were found to have even higher RR. Elevated cholesterol and overweight did not affect RR. It was concluded that EBP can provide a means for earlier identification of hypertensionprone persons.
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The outcome of 1999 apparently healthy men aged 40 to 59 years investigated from 1972 through 1975 was ascertained after 16 years to determine whether systolic blood pressure measured with subjects in the sitting position during a bicycle ergometer exercise test adds prognostic information on cardiovascular mortality beyond that of casual blood pressure measured after 5 minutes of supine rest. During a total follow-up of 31,984 patient years, 278 patients died, 150 from cardiovascular causes. Casual blood pressure and pulse pressure as well as peak exercise systolic blood pressure during 6 minutes on the starting workload of 600 kpm/min (approximately 100 W, 5880 J/min) were all related to cardiovascular mortality. The relative risk (RR) of dying from cardiovascular causes associated with an increment of 48.5 mmHg (= 2 SD) in systolic blood pressure at 600 kilopondmeter (kpm)/min was significant (RR = 1.5, 95% confidence interval [CI] = 1.1-2.3, P = .040) even when adjusting for a large number of variables measured in the present study, including age, exercise capacity, smoking habits, and casual blood pressures. The influence of blood pressure at 600 kpm/min was so strong that the predictive value of resting casual blood pressures became nonsignificant when these were analyzed as continuous variables also including exercise blood pressure as a covariate. However, the maximal systolic blood pressure during the exercise test was unrelated to cardiovascular mortality.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
Exercise hypertension has been suggested to predict future resting hypertension, but its significance in terms of cardiovascular risk has not been defined. To assess the prognostic significance of exercise hypertension, 150 healthy, asymptomatic subjects with normal resting blood pressures and exercise systolic blood pressures > or =214 mm Hg (i.e., >90th percentile) on Bruce treadmill tests were identified retrospectively and age- and gender-matched with subjects with exercise systolic blood pressures of 170 to 192 mm Hg (40th to 70th percentiles). Subjects were contacted by survey a mean of 7.7+/-2.9 years after the index treadmill test. The survey response rate was 93%. There were 12 deaths, including 8 in the exercise hypertension group. A major cardiovascular event, defined as cardiovascular death, myocardial infarction, stroke, coronary angioplasty, or coronary bypass graft surgery occurred in 5 controls and 10 subjects with exercise hypertension. At follow-up, 13 controls and 37 subjects with exercise hypertension were now diagnosed as having resting hypertension. In multivariate analysis, exercise hypertension was not a significant predictor for death or any individual cardiovascular event, but was for total cardiovascular events and new resting hypertension. The multivariate risk ratio for exercise hypertension was 3.62 (p = 0.03) in predicting a major cardiovascular event. Other significant predictors included body mass index and age. For predicting new resting hypertension, the multivariate odds ratio for exercise hypertension was 2.41 (p = 0.02). These data suggest that exercise hypertension carries a small but significant risk for major cardiovascular events in healthy, asymptomatic persons with normal resting blood pressures.
Article
The relation of maximal exercise systolic pressure to physical conditioning and to mortality was determined in 641 men with > or =1 myocardial infarctions. Each performed a standardized multistage exercise test before randomized assignment either to an exercise group or a control group and at scheduled periodic intervals over 3 years. This study compares 123 men with maximal exercise systolic pressures (MESP) of < or =140 mm Hg with 518 men whose maximal exercise systolic pressure was > or =140 mm Hg. At baseline, the 2 groups were comparable for age, entry time since the occurrence of the qualifying cardiac event, and reported use of antihypertensive medications. Men with low MESP used more beta blockers, had lower systolic pressure measurements at rest and by definition at maximal exercise, and lower work capacity than men with higher levels of MESP. Men with low MESP experienced: (1) no reduction in mortality with exercise conditioning (p<0.86), and (2) a significantly higher mortality rate over 3 years (p<0.003) compared with men with higher levels of MESP. The relation of a low MESP to mortality persisted: (1) whether MESP or work capacity increased from the baseline exercise test to the last performed exercise test, and (2) whether it was measured at low (<6 METs) or high (> or =6 METs) levels of work capacity. We conclude that low maximal exercise systolic blood pressure is a predictor of mortality and is associated with an ineffective training response in men with myocardial infarction.
Article
The resting cardiac output measurements presented in the preceding article are analyzed in relation to intra-arterial pressure to provide estimates of peripheral circulatory state and of central cardiac performance. The calculated agewise increase in net vascular resistance which is responsible for the decrease in perfusion, indicates that circulatory attrition with age, on the average, outstrips the expected reduction in basal metabolism of the individual. Despite this lessened peripheral requirement, one may adduce evidences for a trend toward diminished cardiac reserve with age even in these subjects who revealed no clinical cardiac abnormality. The feasibility of predicting an individual's cardiac output from his blood pressure is commented upon.
Article
To evaluate the importance of exercise testing (ET) parameters and leisure time physical activity in predicting long-term prognosis in middle-aged women hospitalized for acute coronary syndrome (ACS). Women aged <66 years recently hospitalized for ACS in the Greater Stockholm area in Sweden were recruited. All underwent baseline clinical examinations including ET and then were followed up for 9 years. Nonparticipation in ET had a hazard ratio of 4.26 (95% confidence interval 2.02-8.95) for total mortality and 3.03 (1.03-8.91) for cardiovascular mortality. All ET parameters were significantly different between survivors than nonsurvivors, except for chest pain and ST-segment depression during ET. Sedentary lifestyle and ET parameters were related to total mortality and cardiovascular mortality in a multivariate analysis adjusting for potential confounders. Predictors of total mortality were sedentary lifestyle 2.94 (1.31-6.62), exercise time 1.75 (1.07-2.87) and inadequate haemodynamic responses: low increase in pulse rate 2.04 (1.16-3.60) and systolic blood pressure (SBP) 1.88 (1.19-2.95) from rest to peak exercise. Parameters that predicted cardiovascular mortality were sedentary lifestyle 3.15 (1.13-8.74) and poor increase in SBP 2.76 (1.30-5.86) from rest to peak exercise. The relation of sedentary lifestyle to survival was substantially weakened when exercise parameters were added to the multivariate analysis model. In female patients <66 years surviving ACS, important independent predictors of long-term all-cause mortality were sedentary lifestyle, low physical fitness and inadequate pulse rate and SBP increase during exercise. Predictors of cardiovascular mortality were sedentary lifestyle and inadequate blood pressure response during exercise.
Article
Our aim was to investigate whether exercise-induced increase in systolic blood pressure (BP) measured during exercise stress testing (EST) adds prognostic information to cardiovascular (CV) mortality. EST is ideally suited to evaluate the prognostic power of systolic BP; it not only measures systolic BP response to exercise but also provides information about exercise capacity and other EST variables, which may affect the peak systolic BP. The study population consisted of 6,145 consecutive patients who underwent symptom-limited EST. Using the median value of change in systolic BP from baseline, patients were grouped according to exercise-induced increases in systolic BP<or=43 mm Hg (group A, n=3,062) and >or=44 mm Hg (group B, n=3,083). Multivariate analysis was used to adjust for baseline differences between the 2 groups with CV mortality as the end point for follow-up. Six thousand one hundred forty-five men underwent EST with a mean follow-up of 6.6 years. During follow-up, 676 patients died of CV causes with an average annual CV mortality of 1.6%. CV mortality was significantly higher in group A than in group B (13.7% vs 8.2%, p<0.001). After adjusting for baseline differences in the 2 groups using multivariate analysis, an increase in systolic BP of <or=44 mm Hg was a significant predictor of mortality (hazard ratio 1.2, 95% confidence interval 1.02 to 1.44, p<0.05). In conclusion, systolic BP response to maximal EST adds prognostic information to CV mortality independent of age, ST-segment abnormalities, and exercise capacity. In our study an increment in systolic BP of >or=44 mm Hg during EST was associated with a 23% improvement in survival over a mean follow-up of >6 years.
Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association
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