Combined Impact of Cardiorespiratory Fitness and Exercise Systolic Blood Pressure on Cardiovascular and All-Cause Mortality: A Long-Term Follow-Up Study

Abstract

Both cardiorespiratory fitness (CRF) and exercise systolic blood pressure (ESBP) have been individually linked to adverse cardiovascular outcomes, but their combined impact remains underexplored. Cardiorespiratory fitness and maximal ESBP were assessed during exercise testing at baseline in 4,032 participants with a mean age of 50.7 years. Multivariable Cox regression analyses were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). During a median follow-up of 26.5 years, 1,302 deaths occurred, including 460 cardiovascular disease (CVD) and 296 coronary heart disease (CHD) deaths. Higher CRF showed a strong inverse association with all outcomes. Compared with participants in the lowest CRF category, those in the highest CRF category had substantially lower risks of CHD mortality (HR 0.40, 95% CI 0.23-0.70), CVD mortality (HR 0.32, 95% CI 0.20-0.51), and all-cause mortality (HR 0.42, 95% CI 0.33-0.53). Higher maximal ESBP categories were also associated with lower risks of CHD and CVD mortality; participants in the highest ESBP category had lower risks of CHD mortality (HR 0.52, 95% CI 0.36-0.75) and CVD mortality (HR 0.58, 95% CI 0.43-0.78) compared with those in the lowest category. In joint analyses, participants with medium-low, medium-high, or high CRF had consistently lower mortality risk across all ESBP categories. The most favorable prognosis was observed among individuals with high CRF combined with low ESBP levels. In conclusion, higher CRF is consistently associated with lower CHD, CVD, and all-cause mortality across all ESBP categories. The combined evaluation of sex-specific CRF and exercise blood pressure responses may improve cardiovascular risk stratification.

Keywords: cardiorespiratory fitness; exercise systolic blood pressure; mortality.