Workload-indexed blood pressure response is superior to peak systolic blood pressure in predicting all-cause mortality
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Aims: The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise. We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality. Methods and results: Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan–Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects ( n = 709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (<210 mmHg) and higher SBP/MET-slope (>10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08–1.32) and 1.20 (1.10–1.31), respectively). In subjects with high fitness, a SBP/MET-slope > 6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12–1.45)). Conclusion: In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality. This simple, novel metric can be considered in clinical exercise testing reports.
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A greater rate of systolic blood pressure increase (beyond 10 mm Hg·MET−1) across a full exercise test (submaximal to maximal workloads) is associated with a 20% higher all-cause mortality rate in older-age male veterans followed for 18 years.
“Indeed, Hedman et al. (27) followed 7542 older-age male veterans over 18 yr and found that a greater rate of SBP increase (beyond 10 mm Hg·MET -1 ) across a full exercise test (submaximal to maximal workloads) is associated with a 20% higher all-cause mortality rate.”
From Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing (2022) · cites this paper as [27]
The Abstract reports 7,542 male veterans followed for a median of 18.4 years and associates an SBP/MET-slope above 10 mmHg/MET with 20% higher all-cause mortality. But Exercise assessments says the slope was calculated from blood pressure measured at rest and just before test termination; it does not establish a rate measured across submaximal-to-maximal workloads. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe rate of SBP increase during exercise may be higher in females and may vary with the risk profile of the individual.
“Other studies suggest the rate of SBP increase may be higher in females (25,26) and further vary with the risk profile of the individual (27).”
From Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing (2022) · cites this paper as [27]
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References 35 · Cited by 89
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- Authors
- Hedman, K., Cauwenberghs, N., Christle, J. W., Kuznetsova, T., Haddad, F., & Myers, J.
- Affiliations
- Linköping University (SE)
- Stanford Medicine (US)
- KU Leuven (BE)
- Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA
- VA Palo Alto Health Care System (US)
- Corresponding author
- Hedman, Kristofer
- Venue
- European Journal of Preventive Cardiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2019-09-30
- Volume
- 27
- Issue
- 9
- Pages
- 978-987
- ISSN
- 2047-4873 (ISSN-L)
- 2047-4881
- OpenAlex
- W2977841367
- Cited by
- 89
- References
- 35
- Citations by year
- 2026: 20 · 2025: 16 · 2024: 14 · 2023: 6 · 2022: 12 · 2021: 13 · 2020: 7 · 2019: 1
- FWCI
- 10.61
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Journal of Preventive Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- DiVA (Linkoping University) (submittedVersion, other-oa)
- Funders
- stanford university (Cardiovascular Institute)
- Swedish Fulbright Commission
- svenska sällskapet för medicinsk forskning
- Swedish Heart Foundation
- Östergötland County Council, Sweden
- Topics
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Keywords
- peak systolic blood pressure, blood pressure response to exercise, metabolic equivalents, exercise testing, all-cause mortality, cardiovascular risk, veterans, cardiorespiratory fitness
- MeSH terms
- Adult, Aged, Blood Pressure, Blood Pressure Determination, Cardiovascular Diseases, Exercise Test, Humans, Male, Middle Aged, Predictive Value of Tests, Prognosis, Risk Factors, Risk Assessment, Veterans Health
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