Association of Blood Pressure Responses to Submaximal Exercise in Midlife With the Incidence of Cardiovascular Outcomes and All‐Cause Mortality: The Framingham Heart Study

Abstract

Background Few studies examined the associations of midlife blood pressure ( BP ) responses to submaximal exercise with the risk of cardiovascular outcomes and mortality in later life. Methods and Results We evaluated 1993 Framingham Offspring Study participants (mean age, 58 years; 53.2% women) attending examination cycle 7. We related BP responses to submaximal exercise with prevalent subclinical cardiovascular disease ( CVD ) using multivariable linear regression models. We also related BP responses to submaximal exercise to the incidence of hypertension, CVD , and all‐cause mortality using Cox proportional hazards regression models. Each SD increment of exercise BP was associated with higher log‐transformed left ventricular mass (systolic blood pressure [ SBP] , β=0.02, P =<0.001; diastolic blood pressure [ DBP ], β=0.01, P =0.004) and carotid intima‐media thickness (SBP, β=0.08, P =<0.001). Rapid BP recovery (per 1 SD increment) was associated with lower log left ventricular mass ( SBP recovery ; β=−0.03, P =<0.001) and carotid intima‐media thickness ( SBP recovery , β=−0.07, P =0.003; DBP recovery , β=−0.09, P =0.003). Additionally, Each SD increment of exercise BP was associated with a higher risk of incident hypertension ( SBP , hazard ratio [HR], 1.40; 95% CI , 1.20–1.62; DBP , HR, 1.24; 95% CI , 1.11–1.40) and CVD ( DBP, HR, 1.15; 95% CI , 1.02–1.30). Finally, the multivariable‐adjusted HR for each 1‐SD increment of BP recovery was 0.46 ( SBP recovery , 95% CI , 0.38–0.54) and 0.55 ( DBP recovery , 95% CI , 0.45–0.67) for hypertension; 0.80 ( SBP recovery , 95% CI , 0.69–0.93) for CVD ; and 0.76 ( SBP recovery , 95% CI , 0.65–0.88) for all‐cause mortality. Conclusions Higher submaximal exercise BP and impaired BP recovery after submaximal ...

Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing

“…We have shown that independent of age, sex, resting BP, and traditional CVD risk factors, each 10 mm Hg increase in SBP at a submaximal workload is associated with a 4% increased annual cardiovascular event and death rate (9). A subsequent meta-analysis (10), and other longitudinal studies (7,8), have since confirmed these results. Recent literature also is mostly unanimous with respect to the utility of EEBP during submaximal exercise to predict the future development of hypertension in general populations without high resting BP (6,58).…”

“…There is myriad data to suggest that abnormal BP responses during clinical exercise testing [including exaggerated exercise BP (EEBP)] may reveal a heightened level of CVD risk beyond resting BP. This includes independent associations between EEBP and CVD end points such as events and death (6)(7)(8), incident hypertension (9,10), cardiac structural and functional adaptation (11)(12)(13)(14)(15)(16), and high BP gone undetected by traditional methods of BP assessment performed at rest (17)(18)(19)(20). Thus, exercise BP is likely a useful clinical tool to aid in the detection of high BP and its related CVD risk.…”

The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance

“…The pooled analysis indicated EEBP during various intensities of submaximal exercise was associated with a 36% increased cardiovascular event and mortality rate, with each 10-mmHg increase in systolic BP during submaximal exercise intensities associated with a 4% increased event rate independent of resting BP, age, sex, and other CVD risk factors [ 5 ]. More recent longitudinal studies and a further meta-analysis have confirmed the CVD risk associated with EEBP during submaximal exercise [ 25 , 26 , 27 ].…”

Does exercise stress testing carry an incremental prognostic value beyond resting office blood pressure?

“…Endothelial dysfunction, arterial stiffness and neurohormonal activation [21,22] are implicated in both the exaggerated BP response to exercise as well as the development of hypertension and cardiovascular disease in general. Subclinical structural abnormalities have been demonstrated by echocardiography studies, such as increased left ventricular mass and diastolic dysfunction in patients with exaggerated BP response during exercise [15,23]. The presence of such early signs of left ventricular remodelling has been linked to long-term negative cardiovascular outcomes.…”