EXAGGERATED BLOOD PRESSURE RESPONSE TO EXERCISE: FROM DEFINITIONS TO CLINICAL INTERPRETATION

Abstract

Blood pressure is routinely monitored during graded exercise testing to ensure procedural safety and characterise the haemodynamic response to increasing workload. The blood pressure response to exercise may also provide clinically relevant information not evident from resting values alone. An exaggerated blood pressure response to exercise has been associated with masked hypertension, incident hypertension, and adverse cardiovascular outcomes, particularly in individuals with normal or high normal office blood pressure. Clinical interpretation remains difficult because definitions vary across recommendations and studies, while peak blood pressure is influenced by exercise intensity, achieved workload, exercise capacity, testing modality, measurement conditions, and patient characteristics. The purpose of this narrative review is to summarise the clinical relevance of exaggerated blood pressure response to exercise and to discuss the main limitations of its current interpretation. A focused narrative synthesis of PubMed indexed publications was performed, including hypertension guidelines, exercise testing recommendations, systematic reviews, meta analyses, and original clinical studies. Available evidence suggests that fixed peak systolic blood pressure thresholds are useful for recognising an exaggerated response. However, peak blood pressure alone does not indicate whether the observed high blood pressure is explained by the high workload achieved or represents an excessive rise relative to the workload performed. Workload indexed measures and individualised reference values may refine interpretation, particularly during cycle ergometry, although calculation methods and classification thresholds remain insufficiently standardised. When an exaggerated response is observed during clinically indicated exercise testing, it should prompt reassessment of the patient’s office and out of office blood pressure profile, including home or ambulatory blood pressure monitoring when appropriate, rather than diagnosis of hypertension or treatment adjustment based on the exercise test alone. Future studies should establish reference standards that account for testing modality, age, sex, workload, and clinical context, and determine whether these approaches improve risk stratification and clinical management