Systolic Blood Pressure Response to Exercise Stress Test
and Risk of Stroke
S. Kurl, MD; J.A. Laukkanen, MD; R. Rauramaa, MD, PhD, MSc; T.A. Lakka, MD, PhD;
J. Sivenius, MD, PhD; J.T. Salonen, MD, PhD, MScPH
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Background and Purpose—Systolic blood pressure (SBP) during exercise has been found to predict a future diagnosis of
hypertension, coronary heart disease, and cardiovascular disease death. No studies have been conducted to show a
relationship between SBP during exercise test and stroke. The aim of the present study was to study the associations
between SBP rise, percent maximum SBP at 2 minutes after exercise, and the risk of stroke in a population-based sample
of men with no prior coronary heart disease.
Methods—SBP was measured every 2 minutes during and after the exercise test. The subjects were a population-based
sample of 1026 men without clinical coronary heart disease, antihypertensive medication, or prior stroke at baseline.
During an average follow-up of 10.4 years, there were 46 cases of stroke (38 ischemic strokes).
Results—Men with SBP rise ⬎19.7 mm Hg per minute of exercise duration had a 2.3-fold increased risk of any stroke and
a 2.3-fold increased risk of ischemic stroke compared with men whose SBP rise was ⬍16.1 mm Hg/min. Similarly,
percent maximum SBP at 2 minutes after exercise (SBP at 2 minutes’ recovery divided by maximum SBP) was
associated (highest tertile) with a 4.6-fold increased risk of any stroke and a 5.2-fold increased risk of ischemic stroke.
Conclusions—SBP rise during exercise and percent maximum SBP at 2 minutes after exercise were directly and
independently associated with the risk of all stroke and ischemic stroke. Exercise SBP testing may be recommended as
an additional tool in the prediction of future stroke. (Stroke. 2001;32:2036-2041.)
Key Words: blood pressure 䡲 exercise test 䡲 hypertension 䡲 risk factors 䡲 stroke prevention
E
levated resting systolic blood pressure (SBP) is a common risk factor for stroke.1 Incidence of stroke increases
proportionally to blood pressure. SBP during exercise has
been found to predict hypertension,2–5 coronary heart disease,6,7 and cardiovascular disease (CVD) death.8 –10 However, little is known about the association between SBP
response to physical stress and the risk of stroke.
An excessive elevation of SBP during exercise testing has
been a stronger predictor of mortality due to CVD than SBP
at rest in some previous studies.6,10,11 However, an exercise
SBP measurement has had only limited value in the evaluation of cardiovascular risk in hypertensive men compared
with measurement of resting SBP.12 Physical capacity may
have an effect on the SBP rise, because maximum exercise
capacity varies among individuals. The problem with using
SBP at a fixed workload as a measure of blood pressure
response is that individuals will perform at different percentages of their maximum capacity. The aim of the present study
was to evaluate the associations of the maximum rise in SBP
relative to exercise test duration and SBP during recovery
with the risk of stroke in a population-based sample of men
from eastern Finland.
Subjects and Methods
Subjects
Subjects were participants in the Kuopio Ischemic Heart Disease
Risk Factor Study, which was designed to investigate risk factors for
CVD, atherosclerosis, and related outcomes in a population-based
sample of men in eastern Finland.13 Of the 3433 men aged 42, 48, 54,
or 60 years who resided in the town of Kuopio or its surrounding
rural communities, 198 were excluded because of death, serious
disease (eg, cancer), or migration away from area. Baseline examinations were conducted on 2682 men (82.9%) between March 1984
and December 1989.
Men who had prior stroke (n⫽69) or coronary heart disease
(n⫽677) were excluded. Prevalent coronary heart disease was
defined as either a history of myocardial infarction or angina
pectoris, angina pectoris on effort based on the London School of
Hygiene Cardiovascular Questionnaire,14 or use of nitroglycerin for
chest pain once a week or more frequently. Men who used antihypertensive medication (n⫽268) or who had abnormal SBP response
(n⫽31) also were excluded. We excluded men with any kind of
antihypertensive medication use to avoid a confounding effect of
Received November 2, 2000; final revision received May 8, 2001; accepted June 8, 2001.
From the Research Institute of Public Health (S.K., J.L., T.A.L., J.T.S.) and Department of Public Health and General Practice, University of Kuopio
(J.T.S.); Research Institute of Exercise Medicine (J.L., T.A.L.), Kuopio; Department of Neurology (J.S.), University Hospital of Kuopio, Brain Research
and Rehabilitation Centre Neuron, Kuopio; and Department of Clinical Physiology and Nuclear Medicine (R.R.), University Hospital of Kuopio and
Research Institute of Exercise Medicine, Kuopio, Finland.
Reprint requests to Professor Jukka T. Salonen, Research Institute of Public Health, University of Kuopio, PO Box 1627, 70211 Kuopio, Finland.
E-mail [email protected]
© 2001 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
2036
Kurl et al
these medications on the results. Abnormal SBP response was
defined as SBP decrease or no increase in 3 consecutive measurements during exercise compared with the starting value. Men with a
decrease or no increase in SBP during exercise were excluded
because these subjects have previously been found to have a poor
prognosis, most likely owing to preexisting CVD.15 Complete data
were available for 1026 men.
Exercise Stress Test
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A maximum symptom-limited exercise-tolerance test was performed
with an electrically braked bicycle ergometer.16 For 348 men
(33.9%) examined before June 1986, the testing protocol comprised
a 3-minute warm-up at 50 W followed by a step-by-step increase in
workload by 20 W/min. The remaining 678 men (66.1%) were tested
with a linear increase in the workload at 20 W/min. The SBP rise did
not differ markedly between the 2 protocols. An electrocardiography
(ECG) recording was printed every 30 seconds during exercise. The
Mason-Likar lead system was used, including leads Vl, V5, and
aVF.17 An ECG recording was printed every 30 seconds based on
averages of 6-second intervals during exercise and at least 7 minutes
of recovery while subjects sat on the bicycle. Exercise ECGs were
coded manually by a cardiologist. The criteria for myocardial
ischemia during the exercise test were ischemic ECG changes,
defined as upsloping, horizontal, or downsloping ST-segment depression ⱖ1.0 mm at 80 ms after the J point.
The most common reasons that subjects stopped the exercise test
were leg fatigue (522 men), exhaustion (216 men), breathlessness
(111 men), and pain in the leg muscles, leg joints, or back (42 men).
The test was discontinued because of cardiorespiratory symptoms or
abnormalities in 132 men. These included arrhythmias (47 men), a
marked elevation in systolic or diastolic blood pressure (26 men),
dizziness (4 men), chest pain (5 men), or ECG changes (5 men). For
a total of 3 men, the exercise test was not performed because of
severe CVD or other disease. After the exercise test, each participant
remained seated on the bicycle for 8 minutes. The same protocol was
followed by all participants.
Assessment of Blood Pressure
Resting blood pressures for each subject were obtained by the same
experienced nurse using a random-zero sphygmomanometer after the
subject had rested in the seated position for 5 and 10 minutes. The
mean of these 2 values was used as resting blood pressure. Blood
pressure during exercise was measured and recorded both manually
and automatically when the subject was sitting on the bicycle. Blood
pressure was measured every 2 minutes both manually and automatically during exercise until the test was stopped and every 2 minutes
after exercise. In the present study, we used only manually measured
blood pressure values. The highest SBP achieved during the exercise
test was defined as the maximum exercise SBP. The SBP rise was
defined as an average rise of SBP per minute of exercise test time.
Blood pressure was also measured during recovery after exercise at
regular intervals of 2, 4, 6, and 8 minutes with subjects seated on the
bicycle. Percent maximum SBP at 2 minutes after exercise was
calculated as SBP at 2 minutes’ recovery divided by maximum SBP.
Assessment of Covariates
The collection of blood specimens18 and measurement of serum
lipids19 have been described elsewhere. Assessment of smoking and
alcohol consumption18 –20 was performed as described previously.
Body mass index was computed as the ratio of weight (kg) to the
square of height (m2).
Ascertainment of Strokes
Incident strokes between 1985 and 1992 were ascertained through
the FINMONICA stroke registry.21 Information on incident strokes
between 1993 and 1997 was obtained by computerized linkage to the
national hospital discharge registry. Diagnostic information was
collected from hospitals and classified by 1 neurologist (J.S.) with
diagnostic criteria identical to the FINMONICA criteria. The average follow-up time to the first stroke was 10.4 years. There were 46
Exercise SBP Response and Stroke Risk
2037
TABLE 1. Baseline Clinical Characteristics and SBP
Measurements at Rest and During Exercise Test
Mean (SD)
Range
Age, y
52.5 (4.7)
42.0–60.4
Alcohol consumption, g/wk
68.2 (105.4)
Body mass index, kg/m2
26.4 (3.3)
Cigarette smoking, pack-years
8.00 (15.7)
Serum LDL cholesterol, mmol/L
4.1 (1.02)
Diabetes, %
0.0–888.9
18.8–40.2
0.0–100.0
0.82–7.97
3.1
Resting SBP, mm Hg
Resting diastolic blood pressure, mm Hg
129.4 (16.0)
91.0–206.5
88.4 (10.1)
65.0–136.7
Resting SBP on bicycle, mm Hg
148.0 (21.0)
98.0–260.0
SBP at 2 minutes from start, mm Hg
164.7 (24.0)
106.0–266.0
SBP rise relative to exercise
duration, mm Hg/min
18.8 (4.7)
8.0–74.5
Exercise duration, min
11.6 (2.2)
2.6–21.9
89 (12)
4–133
Percent maximum SBP at 2 min after
exercise
strokes of any type and 38 ischemic strokes. Each definite stroke was
classified as either an ischemic stroke (International Classification of
Diseases [ICD]-9 codes 433 to 434, ICD-10 code I63) or a hemorrhagic stroke (ICD-9 codes 430 to 431, ICD-10 codes I60 to I61).
Statistical Analysis
The associations of SBP during exercise and recovery with the risk
of stroke were analyzed with SPSS Cox proportional hazards’
models. Covariates were entered as uncategorized into Cox models.
Covariates were selected by entering common stroke risk factors
(age, smoking, serum LDL cholesterol, diabetes, body mass index,
and alcohol consumption) in forced Cox models. When the predictive values of resting and exercise SBP were compared, additional
multivariate analyses were performed. In these analyses, resting and
exercise SBP were entered simultaneously in a forced Cox model
with other presented covariates. Relative hazards adjusted for risk
factors were estimated as antilogarithms of coefficients from multivariate models. Their CIs were estimated under the assumption of
asymptotic normality of the estimates. All tests for statistical
significance were 2-sided. Statistical analyses were performed with
SPSS 9.0 software for Windows.
Results
Baseline Characteristics
Mean resting SBP in the entire study population was
129 mm Hg (range 91 to 207 mm Hg; Table 1). Resting SBP
correlated positively with SBP immediately before the exercise test while subjects were seated on the bicycle (r⫽0.70,
P⬍0.001), SBP at 2 (r⫽0.64, P⬍0.001) and 4 minutes of
exercise (r⫽0.61, P⬍0.001), SBP rise per minute of exercise
duration (r⫽0.30, P⬍0.001), maximum SBP (r⫽0.42,
P⬍0.001), and SBP at 2 minutes after exercise (r⫽0.53,
P⬍0.001). The rise in SBP appeared to plateau after 10
minutes of exercise (Figure). The distributions of other
known risk factors for stroke are presented in Table 1. The
characteristics of SBP measurements during exercise test at
baseline according to quartiles of SBP at rest are shown in
Table 2.
Resting SBP and Risk of Stroke
A resting (casual) SBP increase of 1 SD was associated with
a 1.4-fold increased risk of any stroke and a 1.4-fold
2038
Stroke
September 2001
Mean and SD of SBP rise measured during
maximum symptom-limited exercise stress test
every 2 minutes in men free of stroke, coronary
heart disease, and antihypertensive medications at baseline.
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increased risk of ischemic stroke (Table 3). An SBP increase
immediately before the exercise test while subjects were
seated on the bicycle was associated with a 1.4-fold increased
risk of any stroke and a 1.4-fold increased risk of ischemic
stroke (Table 3).
SBP at Moderate Workloads and Risk of Stroke
A 1-SD increment of SBP at 2 and 4 minutes from the start
of the exercise test was associated with an increased risk of
stroke (Table 3). If resting SBP was added into the forced
models, the relationship of SBP at 2 and 4 minutes and resting
SBP was not significant. Maximum SBP was not associated
with the risk of stroke.
SBP Rise During Exercise Test and Risk of Stroke
The SBP rise per minute of exercise duration was associated
with the risk of stroke (Table 3). A 1-SD increment of SBP
rise per minute (18.8 mm Hg) was associated with a 2.3-fold
increased risk of any stroke and a 2.3-fold increased risk of
ischemic stroke. After further adjustment for resting SBP,
SBP rise per minute of exercise duration was associated
almost statistically significantly with the risk of any stroke
(relative risk [RR]⫽2.06, 95% CI 0.99 to 4.49, P⫽0.051).
Men with an SBP rise ⬎19.7 mm Hg per minute of exercise
duration had a 2.3-fold increased risk of any stroke and a
2.3-fold increased risk of ischemic stroke compared with men
whose SBP rise was ⬍16.1 mm Hg/min (Table 4). Additionally, exercise duration was related to the risk of stroke after
adjustment for other known risk factors, excluding maximum
oxygen uptake, as shown in Table 4. Maximum oxygen
uptake correlated strongly with exercise duration (r⫽0.71,
P⬍0.001).
Percent Maximum SBP at 2 Minutes After
Exercise and Risk of Stroke
SBP after exercise was related to an increased risk of stroke.
The RR was 1.6 for any stroke and 1.7 for ischemic stroke at
2 minutes of recovery for an increment of 1 SD (Table 3).
After further adjustment for resting SBP, the respective RRs
were 1.47 (95% CI 1.01 to 2.15, P⫽0.04) for any stroke and
1.58 (95% CI 1.03 to 2.43, P⫽0.03) for ischemic stroke.
Percent maximum SBP at 2 minutes after exercise was related
to an increased risk of stroke (Table 4). A high ratio of SBP
at 2 minutes of recovery and maximum exercise (highest
tertile) was associated with a 4.6-fold increased risk of any
stroke and a 5.1-fold increased risk of ischemic stroke.
Exercise SBP in 2 Protocols
A 1-SD increment of SBP at 2 (RR⫽1.91, 95% CI 1.32 to
2.78, P⬍0.001) and 4 (RR⫽2.12, 95% CI 1.42 to 3.16,
P⬍0.001) minutes from the start of the exercise test was
associated with increased risk of any stroke. Similarly, SBP
rise per minute of exercise duration (RR⫽5.09, 95% CI 1.13
to 23.0, P⫽0.03), SBP at 2 minutes after exercise (RR⫽2.07,
95% CI 1.31 to 3.24, P⫽0.002), and SBP increase immediately before the exercise test while seated on the bicycle
(RR⫽1.60, 95% CI 1.10 to 2.33, P⫽0.02) predicted the risk
of stroke. These associations were not statistically significant
with the first protocol used, mainly because of the small
number of end points in this group of 348 men.
TABLE 2. Characteristics of SBP During Exercise Test in 1026 Men With No History of Stroke, Coronary Heart Disease,
and Antihypertensive Medication at Baseline According to Quartiles of SBP at Rest
Quartiles of Resting Blood Pressure
Mean (SD)
Q1 (SD)
Q2 (SD)
Q3 (SD)
Q4 (SD)
P
Resting SBP on bike
148.2 (21.2)
131.4 (14.2)
141.1 (14.5)
151.3 (15.0)
168.7 (20.2)
⬍0.001
SBP at 2 min of exercise
164.8 (24.0)
147.9 (16.5)
157.1 (17.7)
167.8 (19.4)
186.2 (23.2)
⬍0.001
SBP at 4 min of exercise
175.1 (24.5)
158.0 (17.4)
167.5 (19.7)
179.8 (19.0)
194.9 (24.5)
⬍0.001
Maximal SBP during exercise
210.3 (26.0)
196.7 (22.9)
205.4 (24.7)
214.5 (21.6)
224.4 (26.1)
⬍0.001
18.8 (4.7)
17.4 (3.9)
18.0 (5.2)
19.0 (3.9)
20.9 (4.8)
⬍0.001
188.5 (27.7)
171.3 (26.3)
181.6 (21.7)
193.2 (22.4)
207.8 (26.4)
⬍0.001
SBP rise per min of exercise duration
SBP 2 min after exercise
Q1 indicates quartile 1, ⬍118.5 mm Hg; Q2, 118.5–126.5 mm Hg; Q3, 126.6 –138.5 mm Hg; and Q4, ⬎138.5 mm Hg.
Kurl et al
TABLE 3.
Exercise SBP Response and Stroke Risk
2039
SBP At Rest and During and After Exercise as Risk Factors for Stroke
Any Stroke (n⫽46)
Ischemic Stroke (n⫽38)
Relative Risk
P
Relative Risk
P
Resting SBP before test (16.8 mm Hg)
1.42 (1.09–1.86)
0.01
1.41 (1.05–1.89)
0.02
Resting SBP on bike* (21.6 mm Hg)
1.38 (1.07–1.77)
0.01
1.39 (1.05–1.83)
0.02
2 min from start (24.6 mm Hg)
1.46 (1.11–1.92)
0.006
1.38 (1.02–1.86)
0.04
4 min from start (24.6 mm Hg)
1.52 (1.17–1.97)
0.002
1.51 (1.14–2.00)
0.004
SBP rise per minute of exercise duration† (18.8 mm Hg)
2.32 (1.21–4.45)
0.01
2.33 (1.44–4.75)
0.02
Maximal SBP during exercise (26.8 mm Hg)
1.11 (0.81–1.52)
0.51
1.14 (0.81–1.61)
0.44
SBP at 2 min after exercise (27.7 mm Hg)
1.63 (1.20–2.22)
0.002
1.69 (1.21–2.37)
0.002
Risk Factor (SD)
SBP at moderate workloads
Relative risks are expressed per 1-SD linear sustained increase in each variable of SBP and are adjusted for age, examination years,
alcohol consumption, cigarette smoking, serum LDL cholesterol, diabetes, and body mass index.
*SBP immediately before exercise test while sitting on bicycle.
†Calculated as maximal SBP rise divided by duration of exercise test.
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Discussion
A high SBP rise per minute of exercise and percent maximum
SBP at 2 minutes after exercise were independently associated with an increased risk of stroke in a population-based
sample of men from eastern Finland. Furthermore, high SPB
at 2 and 4 minutes from the start of the exercise test was
related to increased risk of any stroke. SBP rise per minute of
exercise and SBP at 2 minutes after exercise were 2 important
predictors for the risk of stroke after resting SBP was taken
into account. On the basis of our findings, SBP during
exercise appears to add to the prognostic value of SBP at rest.
SBP rise during exercise provides information about the
hemodynamic response to increasing physical stress that is
not available from SBP at rest. Dynamic exercise produces a
large increase in SBP without much change in diastolic blood
pressure.7 In a previous study, the highest CVD mortality rate
was observed in men with both elevated resting and exercise
blood pressure.9 Fagard et al12 reported that SBP at moderate
and peak workloads was directly associated with the risk of
cardiovascular events in hypertensive men. All these studies
were based on cardiovascular events, but there were no
studies concerning SBP during progressive exercise testing
and the risk of stroke. We determined that both SBP at
TABLE 4. SBP Response According to Tertiles of Percent Maximum SBP at 2 Minutes After Exercise and SBP Rise per
Minute of Exercise Time and Risk of Stroke
Any Stroke (n⫽46)
Risk Factor
Relative Risk
(95% CI)
Ischemic Stroke (n⫽38)
P
No. of
Cases
Relative Risk
(95% CI)
P
No. of
Cases
Percent maximum SBP at 2 minutes after exercise* (ratio)
1st tertile (⬍0.85)
1.00 (Reference)
6
1.00 (Reference)
2nd tertile (0.85–0.95)
2.29 (0.86–6.14)
0.10
14
2.46 (0.84–7.18)
0.10
12
3rd tertile (⬎0.95)
4.61 (1.72–12.35)
0.002
26
5.12 (1.74–15.03)
0.003
21
P⫽0.001 for linear trend
5
P⫽0.002 for linear trend
SBP rise per minute of exercise time†
1st tertile (⬍16.1 mm Hg/min)
1.00 (Reference)
2nd tertile (16.1–19.7 mm Hg/min)
1.30 (0.56–3.01)
3rd tertile (⬎19.7 mm Hg/min)
2.26 (1.03–4.94)
10
1.00 (Reference)
0.54
13
1.39 (0.51–3.71)
0.51
10
0.04
23
2.29 (1.13–6.87)
0.03
21
P⫽0.03 for linear trend
7
P⫽0.02 for linear trend
Exercise duration‡
1st tertile (⬍10.5 min)
1.00 (Reference)
9
1.00 (Reference)
2nd tertile (10.5–12.5 min)
1.35 (0.57–3.20)
0.50
13
1.65 (0.60–4.53)
0.33
11
3rd tertile (⬎12.5/min)
2.58 (1.14–5.82)
0.02
24
3.30 (1.26–8.60)
0.01
21
P⫽0.02 for linear trend
6
P⫽0.009 for linear trend
Adjusted for age, examination years, maximal oxygen uptake, alcohol consumption, cigarette smoking, serum LDL cholesterol, diabetes, and body
mass index.
*Percent maximum SBP at 2 minutes after exercise was defined as the ratio of SBP at 2 minutes’ rest and maximal SBP during exercise.
†SBP rise was defined as average rise of SBP per minute of exercise test time.
‡Adjusted for age, examination years, alcohol consumption, cigarette smoking, serum LDL cholesterol, diabetes, and body mass index.
2040
Stroke
September 2001
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moderate fixed workloads and the SBP rise per minute of
exercise were associated with an increased risk of any stroke.
Previous studies have shown that men with exaggerated
response of blood pressure to physical stress are likely to
develop systemic hypertension.5,22 A significant rise in SBP
during exercise may be due to an underlying disease or to
already high blood pressure at rest. The SBP rise primarily
reflects an increase in cardiac output during dynamic exercise. A high rise in SBP during exercise may be a consequence of high exercise capacity. To control for differences in
exercise capacity among individuals with varying cardiac
output, we used the ratio of SBP rise to duration of exercise.
We measured SBP at regular intervals of 2 minutes to study
the risk of stroke at various stages of the exercise test.
An impaired decrease of SBP from peak exercise to rest
may indicate high systemic vascular resistance. Autonomic
dysfunction and vasoreactivity may cause a gradual fall in
SBP after exercise.23 SBP may remain elevated for a longer
time if sympathetic tone does not decrease and vagal tone
does not increase during the postexercise period.22–25 On the
other hand, SBP may decrease more after exercise in fit and
healthy persons than in unfit persons with a high risk of CVD.
Furthermore, regular physical exercise and good physical
fitness were associated with lower blood pressure, especially
in certain hypertensive groups with certain genotypes.26 In the
present study, an impaired fall from maximum SBP to
recovery markedly increased the risk of any stroke. Percent
maximum SBP at 2 minutes after exercise indicated that SBP
remains elevated during recovery from the maximum value,
which may indicate increased systemic vascular resistance.
Therefore, it could be useful to measure SBP after exercise to
detect men at high risk for future strokes.
We can only speculate on the mechanisms by which
elevation in SBP during exercise increases the risk of stroke.
At the same time, it is not known whether the mechanisms are
the same for increases in SBP at rest and during exercise. A
high intraluminal pressure will lead to extensive changes in
endothelium and smooth muscle function in intracerebral
arteries. In subjects with preclinical atherosclerotic changes,
elevated blood pressure during exercise increases shear stress
in the vessel wall, with a resultant increase in the risk of
endothelial injury.25 The increased stress on the endothelium
can increase permeability over the blood-brain barrier and
result in local or multifocal edema.27 Endothelial damage and
change in blood cell– endothelium interaction can lead to
local thrombi formation and ischemic lesions.
Furthermore, hypertension accelerates the atherosclerotic
process in carotid and vertebral arteries,3,28 which usually
starts in the larger extracerebral arteries, particularly in the
carotid bifurcation. This process, with time, spreads distally
to the smaller intracerebral arteries, leading to increased
vascular resistance and hypertension during exercise and
hence the increased risk of cardiovascular events.24 This
mechanism may be the same for the development of stroke in
men with high SBP during exercise. It is possible that the
steep rise in exercise blood pressure produces poor arterial
compliance. This causes a higher SBP rise in subjects with
underlying arteriosclerotic disease or structural vascular
changes and vice versa.25 With increasing age, blood vessels
become less elastic, and peripheral vascular resistance also
increases in older normotensive individuals, which may be
one reason for the steep rise in SBP at physical stress
compared with elevation of SBP at rest.
A possible limitation of the present study is that SBP
recordings may be inaccurate at peak exercise.29 However, it
is easier to measure SBP during a bicycle ergometer test than
during a treadmill test because the arms are not at rest when
subjects are walking on a treadmill. Another potential limitation is the use of indirect arm-cuff sphygmomanometry for
the SBP measurements, although exercise stress testing and
noninvasive SBP measurements reflect real-life practice. A
feature concerning the study design was that we used 2
different protocols, and it appeared that exercise blood
pressure was related strongly to the risk of stroke while a
linear increase of 20 W/min was used without a warm-up
period. Because of the small number of end points among
those men who performed the exercise test with 3 minutes of
warm-up at 50 W/min, we cannot objectively interpret the
results in this group. On the other hand, our primary aim was
to investigate the increase of SBP rise during standardized
exercise testing and to predict the risk of stroke while using
common protocols. Additionally, there is large interindividual variation in exercise capacity that may result in
different SBP responses to exercise. This could be one of the
reasons that maximum SBP during exercise did not have a
predictive value. In fit persons, high SBP during exercise
with long exercise duration may reflect their extensive
cardiac output. Thus, SBP at a fixed workload depends on
physical fitness and represents different levels within spans of
the SBP rise in different individuals. Therefore, we adjusted
for maximum oxygen uptake to minimize the confounding
problems introduced by differences in exercise capacity
between fit and unfit subjects.
Given our results, we can generalize our findings among
subjects with no history of stroke or coronary heart disease
and no use of medication for hypertension. Exercise SBP
response may provide an additional tool to identify subjects at
high risk for future stroke, and measures such as antihypertensive medication and physical exercise may be recommended as primary preventive measures to these highexercise SBP responders. Furthermore, at the same time, it
may be used as a screening tool to identify high-risk individuals for exercise hypertension and stroke among patients
undergoing exercise stress testing in clinical practice. However, more clinical trials are needed before exercise SBP can
be broadly recommended as an additional predictor for
stroke.
In conclusion, subjects with high SBP rise and short
exercise duration were particularly at high risk of future
stroke. Data on the SBP rise during exercise and percent
maximum SBP at 2 minutes after exercise add to prognostic
information on stroke risk among otherwise healthy middleaged men. The SBP during standardized progressive exercise
testing may be a useful tool for prediction of future strokes
and may help identify subjects at high risk of stroke, although
more studies are needed.
Kurl et al
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Stroke. 2001;32:2036-2041
doi: 10.1161/hs0901.095395
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