Variations in and significance of systolic pressure during maximal exercise (treadmill) testing: Relation to severity of coronary artery disease and cardiac mortality

doi:10.1016/S0002-9149(77)80037-4

The American Journal of Cardiology

Volume 39, Issue 6, 1977, Pages 841-848

https://doi.org/10.1016/S0002-9149(77)80037-4 Get rights and content

Variations in clinical noninvasive systolic pressure at the point of symptom-limited exercise on a treadmill were examined in six groups of subjects: 5,459 men and 749 women classified into three categories each. Among the men, 2,532 were asymptomatic healthy, 592 were hypertensive and 1,586 had clinical manifestations of coronary heart disease (that is, typical angina pectoris, prior myocardial infarction or sudden cardiac arrest with resuscitation). Among the women, 244, 158 and 347 were in the corresponding clinical categories. None had had cardiac surgery; all had follow-up status ascertained by periodic mail questionnaires. Reported deaths were reviewed and classified by three cardiologists; 140 deaths were attributed to coronary heart disease, 118 of them in the men classified as having coronary heart disease. The majority of maximal systolic blood pressure readings were reported to the nearest centimeter rather than millimeter of pressure. Retesting of 156 persons from 1 to 32 months later showed that pressure values agreed within 10 percent in two thirds, the overall mean difference was only 8.6 mm Hg and the correlation at maximal exercise was superior to that of the resting observations just before exercise. Hypertensive patients had a significantly greater body weight than normotensive persons. Among men, the lowest maximal systolic pressure was observed in the group with coronary heart disease; among women, the lowest mean pressure was found in the healthy group. Patients with coronary heart disease were slightly older, and only the women showed a significant correlation in maximal pressure with age. Only 5 percent of the variation in maximal systolic pressure in the patients with coronary heart disease was due to a shortened duration of exercise. Maximal systolic pressures correlated fairly well (r = 0.46 to 0.68 for the various groups) with resting systolic pressure, and this relation was independent of the diagnosis of cardiovascular disease in both men and women. Relations between pressure and the number of stenotic coronary arteries and impaired ejection fraction at rest were examined in 22 men without and 182 men with coronary artery disease. Lower maximal systolic pressures were often associated with two or three vessel disease or reduced ejection fraction, or both.

The prognostic value of maximal systolic pressure for subsequent death due to coronary heart disease was examined in the men with coronary heart disease. The annual rate of sudden cardiac death decreased from 97.9 per 1,000 men to 25.3 and 6.6 per 1,000 men as the range of maximal systolic pressure increased from less than 140 to 140 to 199 and to 200 mm Hg or more, respectively. Cardiomegaly, Q waves in the resting electrocardiogram and persistent postexertional S-T depression were more common in men with the lowest systolic pressure at maximal exercise.

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Cited by (100)

Variable prognostic value of blood pressure response to exercise
2018, Journal of Cardiology
Citation Excerpt :
The major findings of the present study were that BP increase during exercise was significantly related to a lower occurrence of future cardiovascular morbidity/mortality in the total patients visiting a cardiovascular hospital, and that among the clinical variables, only peak VO2 showed a significant interaction with this role of BP response, suggesting a limitation in its predictive ability in patients with preserved exercise capacity. The prognostic significance of BP response to exercise has been reported in previous studies [5–7,9,12,13,17–20]. In healthy subjects, an exaggerated (exceeding the 80th–90th percentile) increase in systolic BP during exercise was reported to be associated with worse mortality and cardiovascular morbidity [4,7,17,19,20].
The aim of this study was to evaluate the impact of patient background including exercise capacity on the relationship between the blood pressure (BP) response to exercise and prognosis in patients visiting a cardiovascular hospital.
A total of 2134 patients who were referred to our hospital underwent symptom-limited maximal cardiopulmonary exercise testing, and were followed through medical records and mail. The BP response to exercise was defined as the difference between peak and rest systolic BP. The end point was set as cardiovascular events including cardiovascular death, acute coronary syndrome, hospitalization for heart failure, and cerebral infarction.
During a median follow-up period of 3 years, 179 (8%) patients reached the end point (2.5%/year). Multivariate analysis showed that BP response was independently and negatively associated with the occurrence of the end point. This prognostic significance of BP response was consistent regardless of left ventricular ejection fraction, renal function, presence of heart failure symptoms, the presence of organic heart disease, and hypertension. However, peak VO₂ showed a significant interaction with the effects of BP response on the end point, suggesting that the prognostic value of BP response was limited in patients with preserved exercise capacity.
The role of BP response to exercise as the predictor depends on exercise capacity of each patient.
Upper normal values of blood pressure response to exercise in Olympic athletes
2016, American Heart Journal
Citation Excerpt :
As expected, the physiologic response of CV system to exercise in athletes is characterized by an increase in heart rate and systolic BP (Figure 1), in response to the increased sympathetic drive, and associated to increased cardiac output.6,28–30 In our athlete's cohort, likely due to extensive peripheral vasodilation, the diastolic BP remains usually unchanged even at maximum exercise.6,28 The maximum systolic BPs we identified as threshold values (220 in male and 200 in female) are relatively higher than those reported by ESC (<210 mm Hg for men and <190 mm Hg for women) and ACC/AHA guidelines (<214 mm Hg); as an example, if the established ESC reference values were used in our population, a remarkably large number of healthy athletes (12% male and 21% female) would have been (mis)classified as abnormal BP responders.4,12
Exercise test is widespread performed in athletes to assess cardiovascular adaptations during effort; however, scarce information exists relative to the behavior of blood pressure during exercise in athletes. We sought to define the normal values and upper limits of blood pressure response to exercise in a large population of elite, healthy athletes.
A total of 1,876 healthy, normotensive elite athletes (aged 25 ± 6 years, 64% male) underwent a comprehensive clinical evaluation including maximal bicycle exercise test.
At maximum exercise, the systolic blood pressure increased significantly (Δ = +69 ± 18 mm Hg; P< .001), whereas diastolic blood pressure showed minimal change (Δ = +1 ± 7 mm Hg; P= .001). The upper reference values were 220 mm Hg in male and 200 mm Hg in female athletes for systolic blood pressure, and 85 mm Hg in male and 80 mm Hg in female for diastolic blood pressure. A subgroup of 142 athletes (7.5%) showed high blood pressure response to exercise, that is, increase in systolic and/or diastolic blood pressure above the 95th percentile. Multivariate logistic regression analysis showed that endurance and mixed sport disciplines, body mass index, and baseline systolic blood pressure were the strongest determinants for high blood pressure response to exercise.
The gender-specific reference values for systolic and diastolic blood pressure at maximum exercise in athletes were defined. A small subset (7.5%) of athletes showed higher blood pressure response, in the absence of target organ disease or metabolic abnormalities, and associated with superior physical performance and larger cardiac remodeling.
Exaggerated exercise blood pressure response and risk of stroke in patients referred for stress testing
2014, European Journal of Internal Medicine
There is some evidence to suggest that exercise systolic blood pressure (SBP) may be associated with future risk of stroke in subjects without a history of coronary artery disease (CAD). However, the value of an exaggerated exercise SBP response (EESBPR) for predicting stroke in patients referred for stress testing for clinical reasons has not been investigated.
We evaluated a community-based sample of 10,047 patients with known or suspected CAD who underwent treadmill exercise echocardiography. An EESBPR was defined as a peak exercise SBP of > 220 mmHg. The ratio of the increase in SBP during exercise to exercise workload (ΔSBPeEW) was also estimated. The endpoints were stroke of any type, ischemic stroke and hemorrhagic stroke. Median follow-up was 3.5 years.
Annualized rates of stroke of any type, ischemic stroke and hemorrhagic stroke were 0.6% (95% CI 0.53–0.67), 0.49% (95% CI 0.42–0.56) and 0.12% (95% CI 0.09–0.15) in patients without EESBPR vs. 0.69% (95% CI 0.37–1), 0.49% (95% CI 0.23–0.76) and 0.19% (95% CI 0.02–0.35) in those with EESBPR (p = 0.68, 0.90 and 0.39, respectively). Similarly, there was no significant univariate association between ΔSBPeEW and the occurrence of any endpoint. In multivariate analysis, hypertension, male sex, age, diabetes mellitus and resting SBP remained predictors of stroke of any type. EESBPR and ΔSBPeEW were not predictors of any of the endpoints evaluated.
We did not observe any significant association between exercise SBP and the future occurrence of stroke in patients with known or suspected CAD referred for exercise echocardiography.
Prognostic Value of an Exaggerated Exercise Blood Pressure Response in Patients With Diabetes Mellitus and Known or Suspected Coronary Artery Disease
2010, American Journal of Cardiology
The prognostic value of an exaggerated exercise systolic blood pressure response (EESBPR) remains controversial. Our aim was to assess whether an EESBPR is associated with the long-term outcome in patients with diabetes mellitus and known or suspected coronary artery disease (CAD). From an initial population of 22,262 patients with known or suspected CAD who underwent treadmill exercise electrocardiography or exercise echocardiography at our institution, 2,591 patients with a history of diabetes mellitus were selected for the present study. EESBPR was defined as systolic blood pressure >220 mm Hg during exercise. The end points were all-cause mortality and hard events (ie, death or myocardial infarction). A total of 236 patients (9.1%) developed an EESBPR during the tests. During a mean follow-up of 6.5 ± 3.9 years, 484 patients died and 646 experienced hard events. The 10-year mortality rate was 16.6% in patients with an EESBPR compared to 30.9% in those without an EESBPR (p <0.001). The 10-year hard event rate was also lower in patients with an EESBPR (23.2% vs 38.9% in patients without an EESBPR; p <0.001). On multivariate analysis, an EESBPR remained independently associated with a lower risk of all-cause mortality (hazard ratio 0.53, 95% confidence interval 0.36 to 0.78, p = 0.001) and hard events (hazard ratio 0.57, 95% confidence interval 0.41 to 0.79; p <0.001). These results remained consistent in the subgroup of patients without a known history of CAD. In conclusion, an EESBPR was associated with improved survival and a lower rate of death or myocardial infarction in patients with diabetes mellitus and known or suspected CAD.
Exercise hypertension: an adverse prognosis?
2009, Journal of the American Society of Hypertension
We sought to clarify the prognostic importance of an “exaggerated” or “hypertensive” systolic blood pressure response to exercise during an exercise test. Studies evaluating the prognosis for cardiovascular events and cardiovascular mortality in those with hypertension during exercise testing were systematically reviewed. Fourteen studies were identified. Six studies were of healthy volunteers or hypertensives. Eight studies were in subjects with known or suspected heart disease. Without established heart disease, exercise hypertension predicted cardiovascular events and cardiovascular death. However, two of the six studies included a multivariate analysis; both demonstrated no independent association. Studies in subjects with known or suspected heart disease demonstrated that exercise hypertension predicted fewer cardiac events and lesser mortality or, after multivariate adjustment, no associated risk. In a healthy population, a higher exercise blood pressure may indicate hypertension or prehypertension, instead of normal vascular function, and an associated long-term adverse prognosis. In a population with a high burden of heart disease, the highest risk subjects with the most extensive cardiac disease may not be capable of generating pressure or workload to allow the manifestation of exercise systolic hypertension. By comparison, therefore, those with exercise hypertension have a better prognosis.
The Blood Pressure Response to Dynamic Exercise Testing: A Systematic Review
2008, Progress in Cardiovascular Diseases
Citation Excerpt :
In population-based studies, lower maximal SBPs have often been associated with more severe CAD, reduced ejection fraction, or both. In a study that included 6208 subjects, Irving et al2 reported a decrease in the annual rate of sudden cardiac death from 98 to 25 to 7 per 1000 men as the range of maximal SBP increased from less than 140 to 140-199 to greater than 200 mm Hg, respectively. Cardiomegaly, Q waves in the resting ECG and persistent postexertional ST depression were found to be more common with patients with the lowest SBP values at maximal exercise.
Although blood pressure (BP) is measured routinely during exercise testing, its clinical significance is not fully understood or appreciated. As the number of studies has increased, conflicting data have emerged, partly due to differences in methodologies, populations studied, testing procedures, and definitions used for an abnormal BP response. This article attempts to review the literature studying the physiology and pathophysiology of the BP response to exercise testing and summarize the evidence for its diagnostic and prognostic applications.

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^*: This research was supported by Grant HL 13517 from the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Public Health Service, Bethesda, Maryland, the Poncin Scholarship Fund of the Seattle First National Bank, Seattle, Washington and a travel grant from the Wellcome Foundation, London, England.

^*: Visiting scientist from the Department of Cardiology, the Royal Infirmary, Edinburgh, Scotland.

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Symposium On Identification And Management Of The Candidate For Sudden Cardiac DeathVariations in and significance of systolic pressure during maximal exercise (treadmill) testing: Relation to severity of coronary artery disease and cardiac mortality*

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Seattle Heart Watch: initial clinical, circulatory and electrocardiographic responses to maximal exercise

Am J Cardiol

Symposium On Identification And Management Of The Candidate For Sudden Cardiac Death
Variations in and significance of systolic pressure during maximal exercise (treadmill) testing: Relation to severity of coronary artery disease and cardiac mortality*