Exaggerated systolic hypertensive response to exercise predicts cardiovascular events: a systematic review and meta-analysis

Pol Arch Intern Med. 2019 Dec 23;129(12):855-863. doi: 10.20452/pamw.15007. Epub 2019 Oct 2.


Introduction: The pathophysiology of exaggerated systolic hypertensive response to exercise (SHRE) is not fully understood, with contradictory data on its role in predicting cardiovascular (CV) events.

Objectives: The aim of this review and meta‑analysis was to assess the association of SHRE with CV clinical outcomes in healthy normotensive individuals.

Patients and methods: We searched PubMed (MEDLINE), Cochrane Library, RefWorks, and Google Scholar to identify clinical studies that reported data on CV event rates and outcomes for patients with SHRE on exercise stress testing. Sensitivity and specificity analysis for assessing the diagnostic accuracy of the SHRE cutoff associated with CV events was estimated using hierarchical summary receiver operating characteristic analysis.

Results: We included 8 studies with 47 188 participants and a median follow‑up of 19.3 years. Exaggerated SHRE was found in patients with composite events (CV mortality and coronary artery disease; hazard ratio [HR], 1.363; 95% CI, 1.135-1.604; P <0.001), in those with coronary artery events (HR, 1.532; 95% CI, 1.240-1.893; P <0.001), and in those with CV mortality (HR, 1.286; 95% CI, 1.075-1.539; P =0.006), as compared with individuals with normal response. An exercise systolic blood pressure of 196 mm Hg predicted CV events with a sensitivity of 62% (54%-69%) and specificity of 75% (60%-86%), with a positive likelihood ratio of less than 3 and a strong correlation (r = -0.71).

Conclusions: Our study supports the clinical relevance of exaggerated SHRE as a predictor of composite and individual CV clinical outcome. These findings should be considered as thought‑provoking evidence for better stratification and, consequently, for optimal management of this high‑risk population.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Pressure / physiology*
  • Exercise / physiology*
  • Exercise Test
  • Female
  • Humans
  • Hypertension / diagnosis*
  • Hypertension / etiology*
  • Hypertension / physiopathology*
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Risk Factors
  • Sensitivity and Specificity
  • Young Adult