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Original research article
Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling
  1. Kristofer Hedman1,2,
  2. Kegan J Moneghetti1,3,
  3. Jeffrey W Christle1,3,
  4. Shadi P Bagherzadeh1,2,
  5. Myriam Amsallem1,2,
  6. Euan Ashley1,3,
  7. Victor Froelicher1,3,
  8. Francois Haddad1,2
  1. 1 Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA
  2. 2 Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
  3. 3 Stanford University, Stanford Sports Cardiology, Stanford, California, USA
  1. Correspondence to Dr Kristofer Hedman, Department of Medicine, Division of Cardiovascular Medicine, Stanford, CA 94025, USA; kristofer.hedman{at}


Objectives To explore blood pressure (BP) in athletes at preparticipation evaluation (PPE) in the context of recently updated US and European hypertension guidelines, and to determine the relationship between BP and left ventricular (LV) remodelling.

Methods In this retrospective study, athletes aged 13–35 years who underwent PPE facilitated by the Stanford Sports Cardiology programme were considered. Resting BP was measured in both arms; repeated once if ≥140/90 mm Hg. Athletes with abnormal ECGs or known hypertension were excluded. BP was categorised per US/European hypertension guidelines. In a separate cohort of athletes undergoing routine PPE echocardiography, we explored the relationship between BP and LV remodelling (LV mass, mass/volume ratio, sphericity index) and LV function.

Results In cohort 1 (n=2733, 65.5% male), 34.3% of athletes exceeded US hypertension thresholds. Male sex (B=3.17, p<0.001), body mass index (BMI) (B=0.80, p<0.001) and height (B=0.25, p<0.001) were the strongest independent correlates of systolic BP. In the second cohort (n=304, ages 17–26), systolic BP was an independent correlate of LV mass/volume ratio (B=0.002, p=0.001). LV longitudinal strain was similar across BP categories, while higher BP was associated with slower early diastolic relaxation.

Conclusion In a large contemporary cohort of athletes, one-third presented with BP levels above the current US guidelines’ thresholds for hypertension, highlighting that lowering the BP thresholds at PPE warrants careful consideration as well as efforts to standardise measurements. Higher systolic BP was associated with male sex, BMI and height and with LV remodelling and diastolic function, suggesting elevated BP in athletes during PPE may signify a clinically relevant condition.

  • Echocardiography
  • Hypertension
  • Cardiac Risk Factors And Prevention
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  • KH and KJM contributed equally.

  • VF and FH contributed equally.

  • Contributors KH and KJM contributed equally to this study as first authors, and VF and FH contributed equally as senior authors. FH, KH, KJM and VF conceptually planned the study, with valuable additions made by JWC, EA, MA and SPB. EA and VF built the database. KJM and FH performed the echocardiography, and SPB, KJM, KH and FH read and/or extracted the data from digital images to a spreadsheet. VF read all ECGs. KH performed the statistical analyses and drafted the first version of the manuscript. All authors contributed in intellectually reviewing and improving the manuscript and approved the final submitted version. All authors agree to be accountable for all aspects of the work.

  • Funding General funding from the Division of Cardiovascular Medicine at Stanford Cardiovascular Institute was used to finalise this project. KH received funding from the Swedish Society of Medicine and the Fulbright Commission.

  • Competing interests None declared.

  • Ethics approval Stanford Institutional Review Board (IRB no. 25673 and IRB no. 12245).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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