Exercise blood pressure relative to fitness in male elite athletes: stage-specific response patterns and athlete-specific reference limits

Abstract Aims An exaggerated blood pressure response (eBPR) to exercise is associated with increased cardiovascular risk. The systolic blood pressure-to-achieved metabolic equivalent (SBP/METpeak) ratio was proposed as a fitness-indexed marker of eBPR in the general population, with 18 mmHg/METpeak suggested as a pragmatic threshold. We aimed to define stage-specific SBP/METpeak reference limits in male elite athletes and examine this comparator. Methods and results We examined 474 healthy male elite athletes (age 25.5 ± 5 y) from mixed sports who underwent a standardized maximal graded cycling test. SBP/METpeak was calculated as the quotient of SBP and peak METs at each workload stage and at peak exercise. Stage-specific percentiles, exceedance rates, and associations with fitness were analysed. Mean achieved workload was 360.7 ± 92.8 W, METpeak 13.1 ± 3.1, maximal SBP 196.9 ± 20.7 mmHg, and peak SBP/METpeak 15.68 ± 3.53 mmHg/METpeak. Stage-wise SBP/METpeak showed a non-linear pattern, increasing from 11.63 ± 2.79 at 100 W to 14.49 ± 3.59 at 250 W and 14.50 ± 3.43 at 300 W, then declining at 350 W (13.40 ± 3.01) and 400 W (12.14 ± 2.89). Stage-specific P75 values peaked at 16.7 mmHg/METpeak at 250–300 W, whereas P90 values reached 18.20–19.27 mmHg/METpeak at 200–300 W. Overall, 21.9% exceeded 18 mmHg/METpeak at least once up to 400 W. Fitness was strongly inversely associated with peak SBP/METpeak (r = −0.811, P 0.001). Conclusion In male elite athletes, SBP/METpeak is workload-dependent and closely linked to aerobic fitness. The 18 mmHg/METpeak comparator aligned primarily with moderate workloads, whereas upper reference values around 16 mmHg/METpeak may better describe the upper range during standardized exercise testing stages in athletes.