Elsevier

Progress in Cardiovascular Diseases

Volume 51, Issue 2, September–October 2008, Pages 135-160
Progress in Cardiovascular Diseases

Special article
The Blood Pressure Response to Dynamic Exercise Testing: A Systematic Review

https://doi.org/10.1016/j.pcad.2008.07.001Get rights and content

Although blood pressure (BP) is measured routinely during exercise testing, its clinical significance is not fully understood or appreciated. As the number of studies has increased, conflicting data have emerged, partly due to differences in methodologies, populations studied, testing procedures, and definitions used for an abnormal BP response. This article attempts to review the literature studying the physiology and pathophysiology of the BP response to exercise testing and summarize the evidence for its diagnostic and prognostic applications.

Section snippets

Methods

We searched for literature in PUBMED (www.ncbi.nlm.nih.gov/sites/entrez/) using the key words “exercise testing,” “systolic blood pressure,” “blood pressure,” “exercise hypotension,” “exercise hypertension,” “left ventricular hypertrophy,” “stroke,” and “blood pressure recovery.” We excluded studies on isometric exercise and those concentrating on patients with cardiomyopathy, valvular disease, and outflow obstructive disease. Using a consensus judgment of the authors to consider the best

Physiology

Exercise requires the body to effectively coordinate multiple responses to the increased metabolic needs of the skeletal muscle while maintaining blood flow to critical tissues such as the heart and brain. With exercise onset, sympathetic activity predominates over vagal tone to increase heart rate and cardiac output while diverting blood flow from low-priority visceral areas to the skeletal muscles. As a result of the increase in cardiac output, mean arterial pressure increases by

Definition and Prevalence

Various definitions have been used to define exercise-induced hypotension (EIH), making the interpretation of the literature problematic. Exercise-induced hypotension is most frequently defined as either (1) a drop in exercise SBP below resting value or (2) an initial increase followed by a subsequent drop of 20 mm Hg or greater while exercising. The optimal definition is still under debate.10

Over the years, numerous studies have established a reliable association in men between hypotension

Definition

Post-exercise, as parasympathetic tone begins to predominate and as HR decreases, SBP tends to decrease sharply. The recovery SBP (RecSBP) ratio is measured as the ratio of SBP after a certain time into recovery vs peak exercise SBP or an earlier RecSBP (to account for differences in peak SBP and inherent measuring error).

This ratio has been proposed as a highly sensitive and specific index for diagnosing CAD. In early studies, the normal upper limit for the RecSBP ratio was 2 SD above the mean

Conclusion

The diagnostic and prognostic significance of an abnormal BP response during exercise and the recovery phase have been evaluated in numerous studies. Despite the emergence of newer diagnostic techniques, BP measurements available from exercise testing can be useful to predict future risk for adverse CV events. However, difficulties in interpreting the literature stem from major differences in definitions, methodologies, and testing procedures as well as population selection. Auscultation of the

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