TOPLINE:

Systolic blood pressure (BP) during exercise was associated with an increased risk for cardiovascular events only when considered in relation to fitness, which was measured in terms of metabolic equivalents (METs). A systolic BP-to-MET ratio could identify increased risk at specific thresholds.

METHODOLOGY:

• Researchers analyzed data from a collaborative study, dubbed EXERTION, to assess whether systolic BP during exercise, considered in relation to a person’s fitness level, was linked to future cardiovascular events.
• They included 12,743 participants (mean age, 52.8 years; 40.1% women) who completed Bruce treadmill tests at six Australian hospitals between 2002 and 2019. BP was measured at rest, during stages 1-4 of the protocol, and at peak exercise.
• Fitness was estimated as peak METs — a standard unit of exercise intensity derived from treadmill speed and incline; higher METs indicate better fitness.
• Researchers calculated the ratio of systolic BP to peak METs (systolic BP/MET_Peak) at each stage and at peak exercise. They categorized this ratio into quartiles and used the lowest quartile as the reference.
• The primary outcome was a composite of fatal and nonfatal cardiovascular events, assessed over a median follow-up period of 51 months.

TAKEAWAY:

• A total of 1349 fatal and nonfatal cardiovascular events occurred during the follow-up period. Absolute systolic BP during exercise at any stage was not associated with the risk for cardiovascular events.
• Each additional MET of peak workload was associated with a 13.9% lower rate of the composite outcome after adjustment for age and sex (P < .001).
• Systolic BP/MET_Peak was linked to a stepwise increase in the risk for cardiovascular events across quartiles. Compared with the lowest quartile, the highest quartile had adjusted hazard ratios of 2.54 (95% CI, 2.08-3.12) at stage 1, 2.05 (95% CI, 1.64-2.57) at stage 2, 1.60 (95% CI, 1.22-2.10) at stage 3, and 2.43 (95% CI, 1.99-2.98) at peak exercise.
• At stage 1, a systolic BP/MET_Peak ≥ 18 mm Hg per MET_Peak was linked to nearly a twofold increase in the risk for the composite outcome. Similar associations were noted for thresholds from 15 to 24 mm Hg per MET_Peak across stages 1-3 and at peak exercise, in both men and women (P < .001).

IN PRACTICE:

“Coupling the prognostic power of fitness with the exercise BP response provides a potential clinical marker upon which to assess CVD [cardiovascular disease] risk related to uncontrolled high BP that cannot be determined from exercise BP and fitness alone,” the researchers of the study wrote.

SOURCE:

The study was led by Martin G. Schultz, of University of Tasmania in Hobart, Tasmania, Australia. It was published online on January 13, 2026, in the European Heart Journal.

LIMITATIONS:

Fitness was estimated with METs from treadmill speed and incline, not direct oxygen measures. Administrative records may not have fully captured the cardiovascular risk factors. Detailed data on medication were largely unavailable.

DISCLOSURES:

One author reported receiving support from a National Heart Foundation of Australia Future Leader Fellowship. The EXERTION study received funding in part by grants from the Royal Hobart Hospital Research Foundation, the National Heart Foundation of Australia, and Diabetes Australia Research Trust. 

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.