Background Guidelines recommend considering workload in interpretation of the systolic blood pressure (SBP) response to exercise, but reference values are lacking. Design This was a retrospective, consecutive cohort study. Methods From 12,976 subjects aged 18–85 years who performed a bicycle ergometer exercise test at one centre in Sweden during the years 2005–2016, we excluded those with prevalent cardiovascular disease, comorbidities, cardiac risk factors or medications. We extracted SBP, heart rate and workload (watt) from ≥ 3 time points from each test. The SBP/watt-slope and the SBP/watt-ratio at peak exercise were calculated. Age- and sex-specific mean values, standard deviations and 90th and 95th percentiles were determined. Reference equations for workload-indexed and peak SBP were derived using multiple linear regression analysis, including sex, age, workload, SBP at rest and anthropometric variables as predictors. Results A final sample of 3839 healthy subjects ( n = 1620 female) were included. While females had lower mean peak SBP than males (188 ± 24 vs 202 ± 22 mmHg, p < 0.001), workload-indexed SBP measures were markedly higher in females; SBP/watt-slope: 0.52 ± 0.21 versus 0.41 ± 0.15 mmHg/watt ( p < 0.001); peak SBP/watt-ratio: 1.35 ± 0.34 versus 0.90 ± 0.21 mmHg/watt ( p < 0.001). Age, sex, exercise capacity, resting SBP and height were significant predictors of the workload-indexed SBP parameters and were included in the reference equations. Conclusions These novel reference values can aid clinicians and exercise physiologists in interpreting the SBP response to exercise and may provide a basis for future research on the prognostic impact of exercise SBP. In females, a markedly higher SBP in relation to workload could imply a greater peripheral vascular resistance during exercise than in males.

BEAUMONT et al. [1] and SCHULTZ et al. [2] should be commended for evaluating the impact of inspiratory muscle training on clinically relevant outcomes in patients with chronic obstructive pulmonary disease (COPD). Chronic breathlessness [3] is a cardinal symptom in people with cardiopulmonary disease and an essential end-point for trials and clinical care. As discussed in one of the papers [1], there were limitations in that breathlessness was not measured at a standardised level of exertion. This limitation is commonly encountered in clinical trials and warrants wider attention.

Summary Introduction A new grading of exercise capacity during bicycle stress testing has been proposed in Sweden based on the new reference material (‘the Kalmar material’), which has not been validated. We aimed to examine the prognostic information of the new grading of exercise capacity during exercise stress testing. Methods Data on all bicycle exercise tests performed at the Department of Clinical Physiology in Kalmar between May 2005 and October 2016 were cross‐linked with the Causes of Death Register (until 30 April 2019) and the National Patient Register (until 12 December 2017). Exercise capacity was graded based on predicted exercise capacity: ≥120% (good), 75 to <120% (normal), 70 to <75% (mildly reduced), 50 to <70% (moderately reduced) and <50% (severely reduced). Associations with all‐cause mortality, cardiovascular mortality and hospitalization for ischaemic heart disease (IHD) and heart failure were analysed using Cox regression. Results A total of 13 887 patients were followed a median of 7·7 years (interquartile range 5·0–10·8); 1809 patients died (546 from cardiovascular disease). Compared to normal exercise capacity, reduction of exercise capacity was strongly associated with increased all‐cause mortality [(hazard ratio; 95% confidence interval): mild (3·0; 2·6–3·5); moderate (4·4; 3·9–4·9); and severe reduction (8·5; 7·2–10·0)]. Reduced exercise capacity was also associated with increased risks of cardiovascular hospitalization and mortality. Conclusion Reduced exercise capacity is associated with increased all‐cause and cardiovascular mortality, as well as increased risk of future IHD and heart failure diagnosis and hospitalization. In patients with reduced exercise capacity, mortality is progressively increased with worsening grade of exercise capacity.

Objectives: This study aimed to evaluate the risk of allcause mortality and incident cardiovascular disease associated with peak systolic blood pressure (PeakSBP) at clinical exercise testing.Methods: Data from 10 096 clinical exercise tests (54% men, age 18-85 years) was cross-linked with outcome data from national registries. PeakSBP was compared with recently published reference percentiles as well as expressed as percentage predicted PeakSBP using reference equations. Natural cubic spline modelling and Cox regression were used to analyse data stratified by sex and baseline cardiovascular risk profile.Results: Median [IQR] follow-up times were 7.9 [5.7] years (all-cause mortality) and 5.6 [5.9] years (incident cardiovascular disease), respectively. The adjusted risk of allcause mortality [hazard ratio, 95% confidence interval (95% CI)] for individuals with PeakSBP below the 10th percentile was 2.00 (1.59-2.52) in men and 2.60 (1.97-3.44) in women, compared with individuals within the 10th-90th percentile. The corresponding risk for incident cardiovascular disease was 1.55 (1.28-1.89, men) and 1.34 (1.05-1.71, women). For males in the upper 90th percentile, compared with individuals within the 10th-90th percentile, the adjusted risks of all-cause death and incident cardiovascular disease were 0.35 (0.22-0.54) and 0.72 (0.57-0.92), respectively, while not statistically significant in women. Spline modelling revealed a continuous increase in risk with PeakSBP values less than 100% of predicted in both sexes, with no increase in risk more than 100% of predicted. Conclusion:Low, but not high, PeakSBP was associated with an increased risk of mortality and future cardiovascular disease. Using reference standards for PeakSBP could facilitate clinical risk stratification across patients of varying sex, age and exercise capacity.

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