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Higher Peak Systolic BP on Exercise Testing May Not Indicate Adverse Vascular Function

Key findings

  • This study quantified blood pressure (BP) responses during maximum-effort cardiopulmonary exercise testing in 2,858 Framingham Heart Study participants, mean age 54, who also had resting arterial stiffness evaluated via tonometry
  • Arterial stiffness and peak O2 pulse (reflecting cardiac and skeletal muscle performance during exercise) were jointly associated with peak systolic BP during exercise
  • Arterial stiffness appeared to have a higher effect on peak systolic BP responses in women than men
  • Systolic BP responses that incorporated workload, especially systolic BP/watts, were more closely related to adverse vascular function metrics in men and women than peak systolic BP

American Heart Association (AHA) standards for cardiopulmonary exercise testing (CPET) recommend using peak systolic blood pressure (SBP) threshold values of ≥210 mmHg in men and ≥190 mmHg in women.

However, Massachusetts General Hospital researchers have demonstrated some individuals achieve higher peak SBP during CPET because of greater fitness levels, not necessarily a higher risk of cardiovascular disease. In Arteriosclerosis, Thrombosis, and Vascular Biology, they recommend using BP measures that incorporate workload.

The authors are Gregory D. Lewis, MD, Jeffrey and MaryEllen Jay chair and section head of the Heart Failure Program, medical director of the Heart Transplant Program and director of the CPET Laboratory; Matthew Nayor, MD, MPH, cardiologist formerly at the Corrigan Minehan Heart Center; and colleagues.


The team analyzed data on 2,858 participants in the Framingham Heart Study (the FHS Generation Three, Omni Generation Two, and New Offspring Spouse cohorts) who agreed to undergo maximum-effort CPET and resting arterial tonometry between 2016 and 2019. Their mean age was 54, and 52% were women.

Principal Observations

The key findings were:

  • About 25% of participants exhibited peak SBP values above the AHA thresholds, but while some had higher arterial stiffness (a physiologically deleterious state), some had lower arterial stiffness and achieved high peak SBP primarily due to greater cardiac stroke volume and oxygen extraction in peripheral tissues (higher peak O2 pulse, a physiologically positive state)
  • Associations of peak O2 pulse with peak SBP were similar in women and men, but carotid–femoral pulse wave velocity (CFPWV), the most widely used noninvasive correlate of arterial stiffness, was more strongly associated with peak SBP in women than men
  • SBP responses that incorporated workload (e.g., SBP at 75 watts, SBP/workload slope) were more closely related to adverse vascular function metrics in men and women than peak SBP
  • Of the exercise BP measures assessed, the SBP/watts slope exhibited the highest effect sizes in relation to higher arterial stiffness and lower O2 pulse across sex and hypertension status

Applying the Results to the Clinic

These findings have several clinical implications:

  • High peak SBP may not be a good predictor of adverse clinical outcomes at the population level
  • Information about cardiorespiratory fitness, peak workload achieved, and cardiac-peripheral exercise performance (obtainable via CPET) is likely to provide important contextual information about exercise performance
  • As suggested in other recent research, the SBP/watts slope may be a superior measure of adverse exercise BP responses

Learn more about the Heart Failure and Transplantation Program

Refer a patient to the Corrigan Minehan Heart Center


Mayooran Namasivayam, MBBS, PhD, Gregory D. Lewis, MD, and colleagues demonstrated that lower proportionate pulse pressure during exercise testing of patients who have heart failure with preserved ejection fraction is associated with a 47% reduced risk of adverse cardiovascular outcomes.


Massachusetts General Hospital researchers found transplantation of hearts donated after circulatory death and preserved with a proprietary ex vivo warm perfusion system was safe and effective compared with control subjects who received hearts donated after brain death. The one-year survival rate was 97%.