Blood Pressure Trajectories during Graded Exercise for the Prediction of Future Hypertension

An exaggerated increase in systolic blood pressure (SBP) during exercise is associated with future hypertension. While previous studies evaluated peak SBP or two-point slopes, we aimed to identify SBP response patterns from the full SBP time-series during maximal incremental exercise and assess their value for predicting future hypertension diagnosis.

In this cohort study, we analysed SBP recordings from 3,486 normotensive adults (mean age 50.6 years; 45% women) undergoing maximal cycle ergometry. Group-based trajectory modelling (GBTM) extracted sex-specific responses from the full SBP time-series. Associations with incident hypertension were evaluated using multivariable Cox analyses by sex and stratified by prehypertensive status (SBP 130-150 mm Hg or DBP 85-90 mm Hg).

In both sexes, GBTM identified three SBP response profiles, reflecting low, mid, and high responders. Over 7.9 years, 171 (8.8%) men and 169 (10.9%) women were diagnosed with hypertension. Incidence was markedly higher in high versus low responders (e.g., in women: 27.8 vs. 2.5 events per 1,000 follow-up years). The increased risk was independent of traditional risk factors, including resting SBP (hazard ratio relative to average risk (HRadj): 1.26 [95% confidence interval: 1.00-1.57] in men, 1.59 [1.22-2.07] in women). The association attenuated with increasing resting SBP in women (p _interaction = 0.003). Notably, high SBP response was independently associated with future hypertension diagnosis in those without prehypertension (e.g., in women, HRadj: 2.17 [1.49-3.17]), but not in those with prehypertension. Reclassification analyses indicated incremental predictive value beyond resting and peak SBP in women without prehypertension.

Time-series analysis of exercise SBP revealed distinct response profiles predicting future hypertension diagnosis beyond resting blood pressure. Comprehensive interpretation of exercise SBP may improve risk stratification, particularly in women without prehypertension.