Evaluating Blood Pressure Response Patterns to Exercise Stress Testing

A hypertensive response to exercise unmasks hypertension and is associated with future cardiovascular events. Yet, there is heterogeneity in blood pressure response patterns to exercise by age and sex, and some high-risk trajectories may go undetected if only focusing on peak blood pressure.

We analyzed blood pressure data from 13 945 patients who underwent a Bruce protocol exercise tolerance test between 2016 and 2020, including the rate of change across stages. We used latent class analysis to identify distinct blood pressure trajectories and assessed their association with individual and composite outcomes of myocardial infarction, stroke, heart failure, revascularization, and death.

Women had lower mean systolic and diastolic blood pressure at rest (128 mm Hg versus 132 mm Hg; 78 mm Hg versus 80 mm Hg) and through stages 1 to 3 of the Bruce protocol (stage 1: 140 mm Hg versus 144 mm Hg; 78 mm Hg versus 80 mm Hg; stage 2: 153 mm Hg versus 157 mm Hg; 79 mm Hg versus 81 mm Hg; stage 3: 159 mm Hg versus 167 mm Hg; 80 mm Hg versus 82 mm Hg). Systolic blood pressure increased more slowly in women. Three distinct systolic blood pressure trajectories emerged, with steeper trajectories associated with older populations and men. Systolic Classes II and III, characterized as an elevated baseline and a gradual rise (Class II) and a steep rise (Class III) with exercise, were associated with cardiovascular outcomes. Yet, only 1.4% and 34% of patients in Class II and III, respectively, met traditional criteria for hypertensive response to exercise, suggesting missed opportunities for prevention and treatment.

Blood pressure response to exercise varies by sex; models incorporating trajectories of blood pressure could more fully capture individuals at higher risk for future cardiovascular events.