Differential Impacts of Resting and Exercise-related Blood Pressure Changes on Cardiovascular and All-cause Mortalities

Background The prognostic significance of BP changes during exercise remains unclear. This study investigated the association between exercise-related BP and long-term mortality. Methods We analyzed 19,110 individuals (mean age 57.9 years, 61.9% men) who underwent clinically indicated treadmill exercise testing. The recordings of BP throughout the test were obtained, and maximal and recovery changes in SBP (ΔSBP_max and ΔSBP_rec) were calculated. Mortality and cardiovascular (CV) death were obtained via linkage to the National Death Registry. Results During a mean follow-up of 4.4±2.6 years, there were 649 deaths and 134 CV deaths. Higher resting SBP, recovery SBP, maximal exercise SBP, peak heart rate, ΔSBP_max, and ΔSBP_rec were inversely associated with CV and all-cause mortality. In contrast, a drop in recovery SBP below resting levels was associated with higher mortality. After multivariable adjustment for age, sex, lipid profiles, diabetes, use of antihypertensive agents, resting SBP, and metabolic equivalents, both ΔSBP_max and ΔSBP_rec remained independently predictive. Specifically, for per 1-SD increase, ΔSBP_max was associated with a hazard ratio (HR) of 0.80 (95% CI, 0.67-0.97) for CV death and 0.88 (95% CI, 0.80-0.96) for all-cause death. Similarly, ΔSBP_rec was associated with an HR of 0.75 (95% CI, 0.62-0.90) for CV death and 0.85 (95% CI, 0.77-0.93) for all-cause death. Conclusions Greater SBP increases during exercise and recovery were associated with lower CV and all-cause mortality, while a drop in recovery SBP identified elevated risk. Exercise BP responses may serve as simple, clinically relevant prognostic markers.