Background: The prognostic relevance of a hypertensive response to exercise (HRE) is ill-defined in individuals undergoing exercise stress testing. The aim of this study was to conduct a systematic review and meta-analysis of published literature to determine the value of exercise BP (independent of office BP) for predicting cardiovascular (CV) events and mortality.

Methods: Online databases were searched for published longitudinal studies reporting exercise BP and CV event and mortality rates. Twelve longitudinal studies were identified for review with a total of 46,314 individuals free of significant coronary artery disease with total CV event and mortality rates recorded over a mean follow-up of 15.2 ± 4.0 years.

Results: After adjustment for age, office BP and CV risk factors, an HRE at moderate exercise intensity carried a 36% increased rate of CV events and mortality (95% CI: 1.02–1.83, p=0.039) compared to those with no HRE. Additionally, per 10 mmHg increase in exercise systolic BP at moderate intensity, there was a 4% increase in CV events and mortality, independent of office BP, age and CV risk factors (95% CI: 1.01–1.07, p=0.018). Systolic BP at maximal workload was not significantly associated with increased rate of CV outcomes, whether analysed as a categorical (HR=1.49, 95% CI: 0.90–2.46, p=0.118) or continuous (HR=1.01, 95% CI: 0.98–1.04, p=0.528) variable.

Conclusion: An HRE at moderate exercise intensity during exercise stress testing is an independent risk factor for CV events and mortality. This highlights the need to determine underlying pathophysiological mechanisms and appropriate management of patients with exercise hypertension.