Our aim was to investigate whether exercise-induced increase in systolic blood pressure (BP) measured during exercise stress testing (EST) adds prognostic information to cardiovascular (CV) mortality. EST is ideally suited to evaluate the prognostic power of systolic BP; it not only measures systolic BP response to exercise but also provides information about exercise capacity and other EST variables, which may affect the peak systolic BP. The study population consisted of 6,145 consecutive patients who underwent symptom-limited EST. Using the median value of change in systolic BP from baseline, patients were grouped according to exercise-induced increases in systolic BP<or=43 mm Hg (group A, n=3,062) and >or=44 mm Hg (group B, n=3,083). Multivariate analysis was used to adjust for baseline differences between the 2 groups with CV mortality as the end point for follow-up. Six thousand one hundred forty-five men underwent EST with a mean follow-up of 6.6 years. During follow-up, 676 patients died of CV causes with an average annual CV mortality of 1.6%. CV mortality was significantly higher in group A than in group B (13.7% vs 8.2%, p<0.001). After adjusting for baseline differences in the 2 groups using multivariate analysis, an increase in systolic BP of <or=44 mm Hg was a significant predictor of mortality (hazard ratio 1.2, 95% confidence interval 1.02 to 1.44, p<0.05). In conclusion, systolic BP response to maximal EST adds prognostic information to CV mortality independent of age, ST-segment abnormalities, and exercise capacity. In our study an increment in systolic BP of >or=44 mm Hg during EST was associated with a 23% improvement in survival over a mean follow-up of >6 years.