| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 1999;99:1831-1836.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Blood Pressure Response During Treadmill Testing as a Risk Factor for New-Onset Hypertension
The Framingham Heart Study
From the National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Mass (J.P.S., M.G.L., J.C.E., C.J.O., D.L.); the National Heart, Lung, and Blood Institute, Bethesda, Md (T.A.M., C.J.O., D.L.); the Division of Epidemiology and Preventive Medicine, Boston University School of Medicine, Boston, Mass (J.P.S., M.G.L., J.C.E., D.L.); the Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio (M.L.); and the Divisions of Cardiology and Clinical Epidemiology, Beth Israel Hospital (D.L.), and Department of Medicine, Massachusetts General Hospital, Harvard Medical School (J.P.S., C.J.O), Boston.
Correspondence to Daniel Levy, MD, Framingham Heart Study, 5 Thurber St, Framingham, MA 01702. E-mail dan{at}fram.nhlbi.nih.gov
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—Although systolic blood pressure (SBP) response to exercise has been shown to predict subsequent hypertension in small samples of men, this association has not been studied in a large population-based sample of middle-aged men and women. The purpose of this study was to examine, in normotensive subjects, the relations of SBP and diastolic blood pressure (DBP) during the exercise and recovery periods of a graded treadmill test to the risk of developing new-onset hypertension.
Methods and Results—BP data from exercise testing in 1026 men and
1284 women (mean age, 42±10 years; range, 20 to 69 years) from the
Framingham Offspring Study who were normotensive at baseline were
related to the incidence of hypertension 8 years later. New-onset
hypertension, defined as an SBP 
140 mm Hg or DBP 90
mm Hg or the initiation of antihypertensive drug treatment, occurred
in 228 men (22%) and 207 women (16%). Exaggerated SBP (Ex-SBP 2) and
DBP (Ex-DBP 2) response and delayed recovery of SBP (R-SBP 3) and DBP
(R-DBP 3) were defined as an age-adjusted BP greater than the 95th
percentile during the second stage of exercise and third minute of
recovery, respectively. After multivariable adjustment, Ex-DBP 2
was highly predictive of incident hypertension in both men (OR, 4.16;
95% CI, 2.15, 8.05) and women (OR, 2.17; CI, 1.19, 3.96). R-SBP 3 was
predictive of hypertension in men in a multivariable model that
included exercise duration and peak exercise BP (OR, 1.92; CI, 1.00,
3.69). Baseline resting SBP (
2, 23.4 in men and 34.7 in
women) and DBP (2, 11.3 in men and 13.1 in women) had
stronger associations with new-onset hypertension than exercise DBP
(2, 16.4 in men and 6.1 in women) and recovery SBP
(2, 6.5 in men and 2.1 in women) responses.
Conclusions—An exaggerated DBP response to exercise was predictive of risk for new-onset hypertension in normotensive men and women. An elevated recovery SBP was predictive of hypertension in men. These findings may reflect subtle pathophysiological features in the preclinical stage of hypertension.
Key Words: tests • hypertension • trials
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Hypertension, a key risk factor for cardiovascular disease morbidity and mortality,1 is a highly prevalent condition in the adult population of the United States.2 3 Given the health costs and potential importance of early detection of hypertension, several studies have examined the role of blood pressure (BP) response to exercise as a risk factor for the development of hypertension.4 5 6 7 8 9 10 Most studies addressing this issue have focused on systolic BP response4 5 8 9 and examined either young subjects4 5 7 8 9 10 or small groups of men at risk for hypertension5 6 7 8 10 and have not looked at a large, unselected sample of middle-aged men and women. Other aspects of the dynamic behavior of BP response, such as exercise-induced changes in diastolic BP and recovery BP after exercise and their association with hypertension risk, have not been examined.
The purpose of this study was to (1) examine the BP responses during exercise and early recovery period of a standard exercise test in normotensive men and women and determine their association with risk of developing hypertension during an 8-year follow-up and (2) define the strength and independence of these associations after adjustment for other risk factors.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Subjects
The Framingham Heart Study is a prospective epidemiological study established in 1948 to evaluate potential risk factors for coronary heart disease. The original cohort included 5209 men and women 28 to 62 years old. In 1971, 5124 additional subjects were enrolled into the Framingham Offspring Study. Study design and selection criteria have been published.11 12 13
Subjects for this investigation were Framingham Offspring Study
subjects who had an exercise treadmill test between 1979 and 1983
during a routine, scheduled examination at the Framingham Heart Study
clinic. Subjects were excluded if they met any of the following
criteria: (1) history or clinical evidence of coronary heart
disease, congestive heart failure, or valvular or congenital
heart disease; (2) hypertension, defined as the current use of
antihypertensive medications or a resting BP of 140 mm Hg
systolic or 90 mm Hg diastolic at the index
examination3 ; (3) use of cardiac medication; and (4) age
<20 or >69 years. All subjects entered at least the second stage of
the standard Bruce protocol.14
The diagnoses of myocardial infarction and congestive heart failure were established by a committee of 3 physicians in accordance with published criteria.15 At the index examination, body height and weight measurements, medical history, physical examination, 12-lead resting ECG, and treadmill testing were routinely performed.
Exercise Treadmill Methods
All participants were studied with a multistage exercise
treadmill test according to the Bruce protocol.14 Subjects
remained on the treadmill for up to five 3-minute stages.
Systolic and diastolic BPs were recorded by
cuff when the subject was standing immediately before testing and
during the last minute of each 3-minute exercise stage. Subjects
exercised until reaching an age-specific target heart rate or the
development of symptoms necessitating termination of the test. The
recovery phase was 4 minutes, with BP and heart rate recorded in
the upright (sitting) position at the end of each minute.
BP Measurements
At each routine examination at baseline and at 4-year intervals
thereafter, resting BP was obtained in the left arm twice in the seated
position by an examining physician using a mercury column
sphygmomanometer. The averaged values were then used to derive the
respective examination systolic and diastolic BP.
The index examination was the one performed at the time of the
treadmill testing. BP obtained 8 years after the index examination was
used to identify new-onset hypertension.
Definitions of BP Responses
1. Exaggerated exercise systolic BP (Ex-SBP, stage 2):
Sex-specific, age-predicted systolic BP 95th percentile
during the second stage of exercise.
2. Exaggerated exercise diastolic BP (Ex-DBP, stage 2):
Sex-specific, age-predicted diastolic BP 95th percentile
during the second stage of exercise.
3. Elevated recovery systolic BP (Rec-SBP, 3 minutes):
Sex-specific, age-predicted systolic BP 95th percentile at
the third minute of the recovery phase.
4. Elevated recovery diastolic BP (Rec-DBP, 3 minutes):
Sex-specific, age-predicted diastolic BP 95th percentile
at the third minute of the recovery phase.
5. New-onset hypertension: Systolic BP 140 mm Hg or
diastolic BP 90 mm Hg or use of antihypertensive
medications on follow-up.3
Statistical Analyses
All statistical analyses were sex-specific. Group means
and SDs were used to summarize baseline clinical variables.
Multivariable regression analyses were performed to assess
the strength and independence of association of BP response during
exercise and recovery with new-onset hypertension.
The principal outcome, new-onset hypertension, was coded as no/yes and
was analyzed with logistic regression models.16
Each of the 4 BP responses (exercise and recovery, systolic and
diastolic BP) was assessed separately by means of
unadjusted, age-adjusted, and age plus clinical covariate–adjusted
analyses. The clinical covariates were diabetes, body mass
index, cigarette smoking, alcohol consumption, and baseline resting
systolic and diastolic BP. In addition, the
recovery BP responses were adjusted for the duration of exercise and
peak systolic and diastolic BP during exercise.
Results are summarized by ORs and 95% CIs, with OR expressed for a BP
response 95th percentile value. An association was considered
statistically significant at P<0.05.
A secondary analysis was performed in subjects with high-normal BP (SBP, 130 to 139 mm Hg and DBP, 85 to 89 mm Hg) to assess the additional, incremental value of exercise BP responses over and above baseline BP in predicting new-onset hypertension. Sex-specific age-predicted cutoff points for the 95th percentile value were derived from linear regression models. All analyses were done on a Sparcstation 2 (SUN Microsystems) using the Statistical Analysis System (SAS).17
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Subjects
Of 3867 subjects who attended the baseline examination and underwent treadmill testing, 1557 subjects were excluded from eligibility: 906 were excluded because of hypertension at the index examination, 206 did not attend the follow-up examination, 397 did not enter stage 2 of the exercise treadmill test, 23 had incomplete BP information, and 25 were excluded for age <20 or >69 years. Of the 1026 normotensive men and 1284 normotensive women eligible for this study, 228 men (22%) and 207 women (16%) were newly hypertensive at the 8-year follow-up visit.
The clinical and exercise characteristics of study participants
(n=2310) are summarized in Tables 1
and 2, respectively. Approximately
80% of subjects achieved target heart rate. The mean resting,
exercise, and recovery systolic and diastolic BPs
were higher in men than in women. Sex-specific, age-predicted 95th
percentile values for systolic and diastolic BP at
the second stage of exercise are presented in Table 3. The distribution of BP responses
during stage 2 of exercise and at 3 minutes of recovery are shown in
Figures 1 and 2, respectively.
|
|
|
|
|
Progression to Hypertension
Observed (crude) probabilities of progression to hypertension as a
function of the exercise and recovery BP responses are displayed in
Figures 3 and 4, respectively. Exercise and recovery
systolic and diastolic BP responses exhibited
positive relations to the probability of developing hypertension.
Subjects in the highest decile of exercise and recovery BP responses
had a >40% and >30% probability of developing hypertension,
respectively.
|
|
Logistic regression analyses were used to examine the
association of each BP response variable with new-onset
hypertension. Unadjusted logistic regression analyses showed
that an exaggerated exercise systolic and diastolic
BP response during the second stage of exercise and an elevated
recovery of systolic and diastolic BP at the third
minute of recovery were associated with risk of hypertension both in
men and women (Table 4).
|
After age adjustment, the association with increased odds of developing hypertension persisted for exercise and recovery variables. An exaggerated diastolic BP response during stage 2 of exercise was observed to have the strongest association with new-onset hypertension in both men (OR, 7.46; 95% CI, 2.15, 8.07) and women (OR, 5.06; 95% CI, 2.93,8.76).
After further adjustment for diabetes, smoking, body mass index,
alcohol intake, and baseline systolic and diastolic
BP, the exaggerated diastolic BP response during stage 2 of
exercise remained the strongest predictor of hypertension in both men
(OR, 4.16; 95% CI, 2.15, 8.05) and women (OR, 2.17; 95% CI, 1.19,
3.96) (Table 4
). An elevated systolic BP at the third
minute of recovery (OR, 2.48; 95% CI, 1.33, 4.64) and elevated
diastolic BP at the third minute of recovery (OR, 2.21; CI,
1.14, 4.25) were also predictors of new-onset hypertension in men.
After exercise duration and peak exercise BP as potential confounders
of recovery responses had been accounted for, an elevated
systolic BP at the third minute of recovery remained predictive
of hypertension in men (OR, 1.92; 95% CI, 1.00, 3.69), and there was a
nonsignificant association with recovery diastolic BP
response (OR, 1.66; 95% CI, 0.83, 3.32).
We observed that baseline resting systolic BP
(2, 23.4 in men and 34.7 in women) and resting
diastolic BP (2, 11.3 in men and
13.1 in women) had stronger associations with new-onset hypertension
compared with exercise diastolic BP
(2, 16.4 in men and 6.1 in women) and recovery
systolic BP (2, 6.5 in men and 2.1 in
women) responses. The additional contributions of exercise
diastolic BP response (stage 2) and recovery
systolic response (third minute) to the overall
2 statistic (above that contributed by the
baseline BP) were 9.7% (P<0.0001) and 4.4%
(P=0.004) in men and 2.2% (P=0.01) and 0.86%
(P=0.12) in women, respectively. In an additional
analysis, pulse pressure during the second stage of exercise
(2, 0.35 in men and 0.15 in women) and third
minute of recovery (2, 0.36 in men and 0.08 in
women) did not enter the model.
The additional value of exercise BP responses above resting BP is
graphically presented in Figure 5. Among subjects with high-normal BP
(n=428), a higher propensity to develop new-onset hypertension was
observed in those with a higher quartile of exercise
diastolic and systolic BP response.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
In normotensive men and women, an exaggerated diastolic BP response to exercise was associated with a 2- to 4-fold risk for new-onset hypertension. A diminished recovery systolic BP response was also predictive of hypertension in men. Although previous work has shown exercise-induced hypertension to be predictive of incident hypertension,4 6 10 this is the first prospective population-based study to examine the exercise BP response during treadmill testing as a predictor of new-onset hypertension separately in middle-aged men and women. The findings of this investigation may reflect subtle pathophysiological features in the preclinical stage of hypertension and help extend our understanding of the relation of exercise and recovery BP to new-onset hypertension. The present report also provides 95th percentile values for exercise BP.
Exercise BP Response and Hypertension
Exercise testing provides accurate estimates of BP response to
physical stress,10 18 19 and measurements made during
exercise have been shown to be reproducible.10 18 Also, it
has been hypothesized that the stress of exercise may unmask a latent
tendency toward hypertension.5
Several definitions of exaggerated BP response have been reported, including some based solely on systolic BP and others on systolic and diastolic BP together.4 5 6 7 8 9 10 Scant information is available regarding the examination of each separately. In this study, the exercise diastolic response was predictive of the development of hypertension and was the strongest exercise predictor of hypertension in both men and women. This finding is consistent with an earlier report describing diastolic BP changes with exercise in borderline hypertensives who subsequently went on to develop hypertension.10 The latter study, however, was restricted to men and did not adjust for confounding variables.10 This exercise-induced rise in diastolic BP in the prehypertensive stage is similar to that described in high-risk subjects (with high-normal BP and family history of hypertension)7 and borderline hypertensives10 and can be explained by increased resting peripheral vascular resistance in the early stages of hypertension20 and impaired capacity for exercise-induced vasodilatation.7 10 21 22
The strong relation observed between exaggerated systolic
response and incident hypertension in univariate
analysis (Table 4) was attenuated in
multivariate analysis, suggesting that exercise
systolic response was a weaker predictor of hypertension than
the diastolic response. This finding is at odds with
several other studies that have reported exercise systolic BP
as a strong predictor of hypertension.5 6 10 23 Those
studies included small numbers of female subjects, did not adjust for
confounding variables, and used different cutoff points for
exaggerated BP responses. The CARDIA study, which observed a weak
association between exercise systolic BP response and
hypertension, was restricted to younger subjects and did not separately
examine the diastolic BP or recovery-phase
responses.4 In our study, the exercise protocol was
standard, and BP measurements from the second stage of exercise were
used to limit the influence of exercise duration and physical
conditioning. Also, the predicted cutoff points defining an exaggerated
BP response were age- and sex-specific.
Recovery BP Response and Hypertension
In the age-adjusted models (Table 4), both
systolic and diastolic BP at the third minute of
recovery were associated with new-onset hypertension. After adjustment
for potential confounders, including duration of exercise and peak BP
responses, the recovery systolic BP continued to remain a
predictor of hypertension in men. Our findings are consistent
with earlier reports that examined the recovery response of BP in young
men after submaximal exercise.5 24 Autonomic dysregulation
has been described in the early stages of hypertension.20
Because the immediate postexercise period is associated with a
withdrawal of sympathetic tone and a rebound increase in vagal
tone,25 it is possible that abnormalities of autonomic
control and vasoreactivity could extend into the early recovery phase
of exercise. Consequently, a blunted decline in the
peripheral vascular resistance could explain the elevated
recovery systolic BP in men predisposed to hypertension.
Sex differences in exercise BP response and its association with hypertension could be related to physiological26 or hormonal27 differences in cardiovascular response to exercise. Age is another important determinant of BP response to exercise. Our results concur with a recent report28 suggesting that BP changes with dynamic exercise in normotensive individuals are accentuated with increasing age.
Resting and Exercise BP
We observed a stronger association between resting BP and risk for
subsequent hypertension than with exercise BP. Although this finding is
supported by some studies,4 19 several others have
suggested that BP during exercise is a better predictor of hypertension
than resting BP.6 10 29 This discrepancy probably arises
from differences in methodology, characteristics of the study sample,
and clinical covariates considered in the analyses. In this
study, we have shown the additional value of exercise and recovery BP
responses as predictors of hypertension after adjustment for baseline
systolic and diastolic BP. In a subset
analysis of subjects with high-normal resting BP (subjects at
high risk of developing hypertension), we have shown the additional and
incremental value of exercise systolic and
diastolic BP responses above resting measurements. Subjects
with high-normal resting BP who exhibit an exercise BP response in the
top quartile are more likely to develop resting hypertension in the
future.
Strengths and Limitations
Our study included a large population-based sample in which
referral bias was inherently minimal. An important strength of this
study is the well-characterized study sample. The relatively large
number of subjects who developed hypertension allowed more precise
estimation of the risk of hypertension and permitted adjustment for age
and baseline BP.
Although the reproducibility of BP response during treadmill testing has not been studied at the Framingham Heart Study, earlier reports18 30 have indicated a good reproducibility for BP measured during and after exercise. A potential limitation of the study is that habitual physical activity was not taken into account. The effect of this, however, was diminished by the use of stage 2 BP measurements, which eliminated the effect of endurance and duration of exercise and standardized the exercise response. BP response is also more easily and accurately measured at this level of exercise, which in fact corresponds to levels of daily physical activities. Low-intensity workloads (equivalent to stage 2 Bruce protocol) require a minimum of subject cooperation and allow for more objective and reproducible results.31 The study sample was predominantly white, and it is possible that results from the present study may not be generalizable to other ethnic and racial groups. Although previous work has suggested an association between left ventricular mass and exercise BP response,32 inclusion of echocardiographic findings was beyond the scope of this project.
Clinical Implications
Given the health costs of hypertension and the importance of early
detection of this disorder, exercise and recovery BP responses during
standard treadmill testing may serve as risk markers for new-onset
hypertension. Exercise treadmill testing may help identify individuals
at risk for the development of hypertension in whom closer follow-up is
warranted and in whom nonpharmacological strategies should be
investigated for their ability to prevent hypertension.
Received July 22, 1998; revision received December 1, 1998; accepted February 26, 1999.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. O'Donnell CJ, Ridker PM, Glynn RJ, Berger K, Ajani U, Manson JE, Hennekens CH. Hypertension and borderline isolated systolic hypertension increase risks of cardiovascular disease and mortality in male physicians. Circulation. 1997;95:1132–1137.
2. Garrison RJ, Kannel WB, Stokes J III, Castelli WP. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med. 1987;16:235–251.[Medline] [Order article via Infotrieve]
3.
The Sixth Report of the Joint National Committee on
Prevention, Detection, Evaluation and Treatment of High Blood Pressure
(JNC VI). Arch Intern Med. 1997;157:2413–2446.
4. Manolio TA, Burke GL, Savage PJ, Sidney S, Gardin JM, Oberman A. Exercise blood pressure response and 5-year risk of elevated blood pressure in a cohort of young adults: the CARDIA study. Am J Hypertens. 1994;7:234–241.[Medline] [Order article via Infotrieve]
5. Tanji JL, Champlin JJ, Wong GY, Lew EY, Brown TC, Amsterdam EA. Blood pressure recovery curves after submaximal exercise: a predictor of hypertension at ten-year follow-up. Am J Hypertens. 1989;2:135–138.[Medline] [Order article via Infotrieve]
6. Dlin RA, Hanne N, Silverberg DS, Bar-Or O. Follow-up of normotensive men with exaggerated blood pressure response to exercise. Am Heart J. 1983;106:316–320.[Medline] [Order article via Infotrieve]
7. Wilson MF, Sung BH, Pincomb GA, Lovallo WR. Exaggerated pressure response to exercise in men at risk for systemic hypertension. Am J Cardiol. 1990;66:731–736.[Medline] [Order article via Infotrieve]
8. Molineux D, Steptoe A. Exaggerated blood pressure responses to submaximal exercise in normotensive adolescents with a family history of hypertension. J Hypertens. 1988;6:361–365.[Medline] [Order article via Infotrieve]
9. Iskandrian AS, Heo J. Exaggerated systolic blood pressure response to exercise: a normal variant or a hyperdynamic phase of essential hypertension? Int J Cardiol. 1988;18:207–221.[Medline] [Order article via Infotrieve]
10. Franz IW. Exercise hypertension: its measurement and evaluation. Herz. 1987;12:99–109.[Medline] [Order article via Infotrieve]
11. Dawber TR, Meadors GF, Moore FE. Epidemiologic approaches to heart disease: the Framingham study. Am J Public Health. 1951;41:279–286.
12. Dawber TR, Kannel WB, Lyell LP. An approach to longitudinal studies in a community: the Framingham study. Ann N Y Acad Sci. 1963;107:539–556.
13.
Kannel WB, Feinleib M, McNamara PM, Garrison RJ,
Castelli WP. An investigation of coronary heart disease in
families: the Framingham Offspring study. Am J
Epidemiol. 1979;110:281–290.
14. Ellestad MH. Stress Testing: Principles and Practice. 3rd ed. Philadelphia, Pa: FA Davis; 1986.
15. Kleinbaum DG, Kupper LK, Muller KE. Applied regression analysis and other multivariable methods. Boston, Mass: PWS-Kent: 1988.
16. Hosmer DW Jr, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons, Inc; 1989.
17. SAS/STAT User's Guide, Version 6. Cary NC: SAS Institute Inc; 1989:846–1456.
18.
Pickering TG, Harshfield GA, Kleinert HD, Blank S,
Laragh JH. Short-term effect of dynamic exercise on
arterial blood pressure. Circulation. 1991;83:1557–1561.
19. Goble MM, Schieken RM. Blood pressure response to exercise: a marker for future hypertension? Am J Hypertens. 1991;4:617S–620S.[Medline] [Order article via Infotrieve]
20. Julius S. Abnormalities of autonomic nervous control in human hypertension. Cardiovasc Drugs Ther. 1994;8(suppl 1):11–20.
21. Saitoh M, Miyakoda H, Kitamura H, Kinugawa T, Hisatome I, Kotake H, Mashiba H. Cardiovascular and sympathetic nervous response to dynamic exercise in patients with essential hypertension. Intern Med. 1992;31:606–610.[Medline] [Order article via Infotrieve]
22. Ekstrand K, Nilsson JA, Lilja B, Bostrom PA, Arborelius M. Markers for development of hypertension in commercial flight aviators. Aviat Space Envir Med. 1991;62:963–968.[Medline] [Order article via Infotrieve]
23. Tanji JL, Champlin JJ, Wong GY, Lew EY, Brown TC, Amsterdam EA. Blood pressure at rest and during maximal dynamic and isometric exercise as predictors of systemic hypertension. Am J Cardiol. 1988;62:1058–1061.[Medline] [Order article via Infotrieve]
24.
Davidoff R, Schamroth CL, Goldman AP, Diamond TH,
Cilliers AJ, Myburgh DP. Predictors of systolic blood pressure
response to treadmill exercise: the Lipid Research Clinics Program
Prevalence Study. Circulation. 1983;68:225–233.
25.
Arai Y, Saul JP, Albrecht P, Hartley LH, Lilly LS,
Cohen RJ, Colucci WS. Modulation of cardiac autonomic activity during
and immediately after exercise. Am J Physiol. 1989;256:H132–H141.
26.
Sheffield LT, Maloof JA, Sawyer JA, Roitman D. Maximal
heart rate and treadmill performance of healthy women in
relation to age. Circulation. 1978;57:79–84.
27.
Martin WH III, Ogawa T, Kohrt WM, Malley MT, Korte E,
Kieffer PS, Schechtman KB. Effects of aging, gender, and physical
training on peripheral vascular function.
Circulation. 1991;84:654–664.
28. Daida H, Allison TG, Squires RW, Miller TD, Gau GT. Peak exercise blood pressure stratified by age and gender in apparently healthy subjects. Mayo Clin Proc. 1996;71:445–452.[Abstract]
29. Liebel B, Kobrin I, Ben-Ishay D. Exercise testing in assessment of hypertension. BMJ. 1982;285:1535–1536.
30. Franz IW, Lohmann FW. Reproducibility of blood pressure measurements in hypertensives during and after ergometry. Dtsch Med Wochenschr. 1982;107:1379–1383.[Medline] [Order article via Infotrieve]
31. Jette M, Landry F, Blumchen G. Exercise hypertension in healthy normotensive subjects: implications, evaluation and interpretation. Herz. 1987;12:110–118.[Medline] [Order article via Infotrieve]
32. Lauer MS, Okin PM, Anderson KM, Levy D. Impact of echocardiographic left ventricular mass on mechanistic implications of exercise testing parameters. Am J Cardiol. 1995;12:952–956.
This article has been cited by other articles:
 |
|
 |
|
  U. G. Bronas and A. S. Leon Lifestyle Modifications for Its Prevention and Management American Journal of Lifestyle Medicine, November 1, 2009; 3(6): 425 - 439. [Abstract] [PDF]
|
|
|
|
 |
|
 P Hedberg, J Ohrvik, I Lonnberg, and G Nilsson Augmented blood pressure response to exercise is associated with improved long-term survival in older people Heart, July 1, 2009; 95(13): 1072 - 1078. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. E. Vanhecke, B. A. Franklin, K. C. Zalesin, R. B. Sangal, A. T. deJong, V. Agrawal, and P. A. McCullough Cardiorespiratory Fitness and Obstructive Sleep Apnea Syndrome in Morbidly Obese Patients Chest, September 1, 2008; 134(3): 539 - 545. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. E. Sharman, C. M. McEniery, R. Campbell, P. Pusalkar, I. B. Wilkinson, J. S. Coombes, and J. R. Cockcroft Nitric Oxide Does Not Significantly Contribute to Changes in Pulse Pressure Amplification During Light Aerobic Exercise Hypertension, April 1, 2008; 51(4): 856 - 861. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. T. Larson, L. A. Mynderse, V. K. Somers, M. R. Jaff, W. P. Evans, and T. R. Larson Blood Pressure Surges During Office-Based Transurethral Microwave Therapy for the Prostate Mayo Clin. Proc., March 1, 2008; 83(3): 309 - 312. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. K. Gilliam, J. P. Palmer, and G. J. Taborsky Jr. Tyramine-Mediated Activation of Sympathetic Nerves Inhibits Insulin Secretion in Humans J. Clin. Endocrinol. Metab., October 1, 2007; 92(10): 4035 - 4038. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Hamer and A. Steptoe Association Between Physical Fitness, Parasympathetic Control, and Proinflammatory Responses to Mental Stress Psychosom Med, September 1, 2007; 69(7): 660 - 666. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 X. Bao, C. M. Lu, F. Liu, Y. Gu, N. D. Dalton, B.-Q. Zhu, E. Foster, J. Chen, J. S. Karliner, J. Ross Jr, et al. Epinephrine Is Required for Normal Cardiovascular Responses to Stress in the Phenylethanolamine N-Methyltransferase Knockout Mouse Circulation, August 28, 2007; 116(9): 1024 - 1031. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Ingelsson, M. G. Larson, R. S. Vasan, C. J. O'Donnell, X. Yin, J. N. Hirschhorn, C. Newton-Cheh, J. A. Drake, S. L. Musone, N. L. Heard-Costa, et al. Heritability, Linkage, and Genetic Associations of Exercise Treadmill Test Responses Circulation, June 12, 2007; 115(23): 2917 - 2924. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members:, G. Mancia, G. De Backer, A. Dominiczak, R. Cifkova, R. Fagard, G. Germano, G. Grassi, A. M. Heagerty, S. E. Kjeldsen, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Eur. Heart J., June 11, 2007; (2007) ehm236v1. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Jakulj, K. Zernicke, S. L. Bacon, L. E. van Wielingen, B. L. Key, S. G. West, and T. S. Campbell A High-Fat Meal Increases Cardiovascular Reactivity to Psychological Stress in Healthy Young Adults J. Nutr., April 1, 2007; 137(4): 935 - 939. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Ou, E. Mousseaux, D. S. Celermajer, E. Pedroni, P. Vouhe, D. Sidi, and D. Bonnet Aortic arch shape deformation after coarctation surgery: effect on blood pressure response. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1105 - 1111. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Brassard, A. Ferland, V. Gaudreault, N. Bonneville, J. Jobin, and P. Poirier Elevated peak exercise systolic blood pressure is not associated with reduced exercise capacity in subjects with Type 2 diabetes J Appl Physiol, September 1, 2006; 101(3): 893 - 897. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Steptoe and M. Marmot Psychosocial, Hemostatic, and Inflammatory Correlates of Delayed Poststress Blood Pressure Recovery Psychosom Med, July 1, 2006; 68(4): 531 - 537. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. J. Hautala, T. Rankinen, A. M. Kiviniemi, T. H. Makikallio, H. V. Huikuri, C. Bouchard, and M. P. Tulppo Heart rate recovery after maximal exercise is associated with acetylcholine receptor M2 (CHRM2) gene polymorphism Am J Physiol Heart Circ Physiol, July 1, 2006; 291(1): H459 - H466. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Sharman, R. Lim, A. M. Qasem, J. S. Coombes, M. I. Burgess, J. Franco, P. Garrahy, I. B. Wilkinson, and T. H. Marwick Validation of a Generalized Transfer Function to Noninvasively Derive Central Blood Pressure During Exercise Hypertension, June 1, 2006; 47(6): 1203 - 1208. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Kurl, J.A. Laukkanen, L. Niskanen, R. Rauramaa, T.P. Tuomainen, J. Sivenius, and J.T. Salonen Cardiac Power During Exercise and the Risk of Stroke in Men Stroke, April 1, 2005; 36(4): 820 - 824. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Madias Blunted Decline in Systolic Blood Pressure After Exercise Predicts Future Acute Myocardial Infarction Hypertension, December 1, 2004; 44(6): 807 - 808. [Full Text] [PDF]
|
|
|
|
|
|
J. A. Laukkanen, S. Kurl, R. Salonen, T. A. Lakka, R. Rauramaa, and J. T. Salonen Systolic Blood Pressure During Recovery From Exercise and the Risk of Acute Myocardial Infarction in Middle-Aged Men Hypertension, December 1, 2004; 44(6): 820 - 825. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. M. Mottram, B. Haluska, R. Leano, D. Cowley, M. Stowasser, and T. H. Marwick Effect of Aldosterone Antagonism on Myocardial Dysfunction in Hypertensive Patients With Diastolic Heart Failure Circulation, August 3, 2004; 110(5): 558 - 565. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. M. Mottram, B. Haluska, S. Yuda, R. Leano, and T. H. Marwick Patients with a hypertensive response to exercise have impaired systolic function without diastolic dysfunction or left ventricular hypertrophy J. Am. Coll. Cardiol., March 3, 2004; 43(5): 848 - 853. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Committee Members, R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: A report of the American college of cardiology/American heart association task force on practice guidelines (committee to update the 1997 exercise testing guidelines) J. Am. Coll. Cardiol., October 16, 2002; 40(8): 1531 - 1540. [Full Text] [PDF]
|
|
|
|
|
|
R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, M. G. O'Reilly, et al. ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) Circulation, October 1, 2002; 106(14): 1883 - 1892. [Full Text] [PDF]
|
|
|
|
|
|
N. Miyai, M. Arita, K. Miyashita, I. Morioka, T. Shiraishi, and I. Nishio Blood Pressure Response to Heart Rate During Exercise Test and Risk of Future Hypertension Hypertension, March 1, 2002; 39(3): 761 - 766. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. F. Fletcher, G. J. Balady, E. A. Amsterdam, B. Chaitman, R. Eckel, J. Fleg, V. F. Froelicher, A. S. Leon, I. L. Pina, R. Rodney, et al. Exercise Standards for Testing and Training: A Statement for Healthcare Professionals From the American Heart Association Circulation, October 2, 2001; 104(14): 1694 - 1740. [Full Text] [PDF]
|
|
|
|
|
|
S. Kurl, J. A. Laukkanen, R. Rauramaa, T. A. Lakka, J. Sivenius, and J. T. Salonen Systolic Blood Pressure Response to Exercise Stress Test and Risk of Stroke Stroke, September 1, 2001; 32(9): 2036 - 2041. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Miyai, M. Arita, I. Morioka, K. Miyashita, I. Nishio, and S. Takeda Exercise BP response in subjects with high-normal BP: Exaggerated blood pressure response to exercise and risk of future hypertension in subjects with high-normal blood pressure J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1626 - 1631. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Bouchart, A. Dubar, A. Tabley, P. Y. Litzler, C. Haas-Hubscher, M. Redonnet, J. P. Bessou, and R. Soyer Coarctation of the aorta in adults: surgical results and long-term follow-up Ann. Thorac. Surg., November 1, 2000; 70(5): 1483 - 1488. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 BP Surge on Exercise Testing Predicts Hypertension Journal Watch (General), April 23, 1999; 1999(423): 5 - 5. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||