Prognostic value of exercise blood pressure: role of fitness and exercise training

Abnormal blood pressure (BP) responses to exercise, both hypertensive and hypotensive, are strong independent predictors of cardiovascular morbidity and mortality across populations. Higher cardiorespiratory fitness is associated with lower submaximal exercise BP across populations. Better vascular function and modulation of the autonomic nervous system likely drive this relation. Despite higher absolute BP values, athletes demonstrate lower BP responses relative to metabolic demand. These observations highlight a critical limitation of using absolute thresholds and support indexing exercise BP to metabolic or external workload for improved risk stratification. Furthermore, submaximal exercise BP is a superior target for risk assessment and intervention, as it provides unique prognostic value, predicting adverse events independent of resting BP and other risk factors, and consistently improves with exercise training, unlike the inconsistent response of maximal exercise BP. This review synthesizes the evidence on the prognostic value of exercise BP, its physiological relation with cardiorespiratory fitness, and its response to traditional and emerging exercise interventions. Ultimately, we propose a conceptual model for clinical consideration, designed to guide the integration of exercise BP assessment into practice as a modifiable cardiovascular disease risk factor.