Workload-indexed blood pressure response is superior to peak systolic blood pressure in predicting all-cause mortality

Author:

Hedman Kristofer123,Cauwenberghs Nicholas24,Christle Jeffrey W12,Kuznetsova Tatiana4,Haddad Francois12,Myers Jonathan15

Affiliation:

1. Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA

2. Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA

3. Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

4. Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium

5. Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA

Abstract

Aims The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise. We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality. Methods and results Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan–Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects ( n = 709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (<210 mmHg) and higher SBP/MET-slope (>10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08–1.32) and 1.20 (1.10–1.31), respectively). In subjects with high fitness, a SBP/MET-slope > 6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12–1.45)). Conclusion In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality. This simple, novel metric can be considered in clinical exercise testing reports.

Funder

stanford university

Swedish Fulbright Commission

svenska sällskapet för medicinsk forskning

Swedish Heart Foundation

Östergötland County Council, Sweden

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine,Epidemiology

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