What is the clinical evidence from this study?

Study design: Cohort. Population: Patients undergoing maximal cycle ergometry (n=6107). Intervention: High systolic blood pressure (SBP) trajectory during exercise vs. Lower SBP trajectories. Primary outcome: Major adverse cardiovascular events (MACE) (HR 1.79, 95% CI 1.16-2.76).

What does this research mean for the field?

A high systolic blood pressure response during graded exercise independently predicts future major adverse cardiovascular events among patients who are normotensive at rest. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research aims to analyze blood pressure responses during graded exercise to evaluate their prognostic implications.

May 10, 2026Open Access

Determinants and prognostic value of blood pressure trajectories during graded exercise

Key Result

A high systolic blood pressure response during graded exercise independently predicted future major adverse cardiovascular events among patients who were normotensive at rest (adjusted HR 1.79 in women and 1.36 in men).

Key Points

This research aims to analyze blood pressure responses during graded exercise to evaluate their prognostic implications.
Analyzed systolic blood pressure recordings from 6107 patients during maximal graded exercise testing.
Utilized group-based trajectory modelling to classify distinct blood pressure response patterns by sex.
Employed ordinal logistic regression and Cox survival analyses to assess associations with clinical factors and major adverse cardiovascular events.
Identified four systolic blood pressure and four relative change trajectories from exercise data.
High systolic blood pressure and low relative change were linked to adverse clinical profiles and higher major adverse cardiovascular events incidence.
In normotensive individuals, high systolic blood pressure response indicated greater risk for major adverse cardiovascular events.

Study Design

Type

Cohort (n=6,107)

Structured PICO

Do distinct systolic blood pressure trajectories during graded exercise predict incident major adverse cardiovascular events?

Population

6,107 patients (mean age 55.4 years, 45% women) who underwent maximal cycle ergometry. Excluded: non-bicycle protocols, minors, submaximal tests, poor SBP trace quality, valvular heart disease, pacemaker or implantable defibrillator, class III obesity (BMI ≥40 kg/m2), and presence of arrhythmia during the test.

Intervention

Group-based trajectory modelling (GBTM) of absolute systolic blood pressure (SBP) and relative change (∆SBP) time-series during maximal graded exercise

Comparator

Comparison across four distinct SBP and ∆SBP trajectory groups (low, low-mid, mid-high, and high responses)

Outcome

Incident major adverse cardiovascular events (MACE), defined as cardiovascular death, ischemic heart disease, stroke, or heart failure occurring after the exercise testhard clinical

Time-series analysis of systolic blood pressure during graded exercise identifies distinct trajectory patterns that independently predict MACE, particularly in individuals with resting normotension.

Main Result

Effect estimate: HR 1.79 (95% CI 1.16-2.76)

Limitations

Findings from maximal clinical exercise tests using ramp protocols may not generalize to submaximal or stage-based protocols
SBP measurements during exercise are prone to measurement error
Variation in the timing and number of SBP measurements may have influenced the precision of the trajectory modelling
Requirement of at least four SBP measurements excludes tests with sparse SBP data
Retrospective study design precludes causal inference
The clinical cohort may have underrepresented healthy individuals

Abstract

PURPOSE: The systolic blood pressure (SBP) response to exercise reflects cardiovascular health, with both exaggerated and blunted responses linked to adverse outcomes. Prior studies relied typically on peak SBP or two-point slopes for evaluation. We aimed to identify distinct SBP responses from full times-series recorded during maximal, graded exercise and assess their clinical determinants and prognostic relevance. METHODS: In this cohort study, we analysed SBP recordings from 6107 patients (mean age, 55.4 years; 45% women) who underwent maximal cycle ergometry. Group-based trajectory modelling (GBTM) extracted sex-specific responses from absolute SBP and relative change (∆SBP) traces. Associations with clinical factors and incident major adverse cardiovascular events (MACE) were assessed using ordinal logistic regression and Cox survival analyses, respectively. RESULTS: Per sex, GBTM identified four SBP and four ∆SBP trajectories, with weak overlap between them. Higher SBP and lower ∆SBP trajectories were associated with adverse clinical profiles, including higher age and lower exercise capacity. MACE incidence was highest in the high SBP and low ∆SBP groups, but these response categories did not independently predict MACE after adjustment for resting SBP. Among patients with normotension at rest, however, a high SBP response (along with a low ∆SBP in men) was independently associated with increased MACE risk. Patients presenting both high SBP and low ∆SBP consistently conferred the highest MACE risk. CONCLUSIONS: Time-series analysis of SBP measurements during graded exercise revealed distinct response patterns with value for MACE prediction, particularly in normotensive individuals. Integrating such analyses into exercise testing may refine cardiovascular risk stratification.

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