How blood pressure changes during exercise predicts heart attacks better than peak readings

PURPOSE: The systolic blood pressure (SBP) response to exercise reflects cardiovascular health, with both exaggerated and blunted responses linked to adverse outcomes. Prior studies relied typically on peak SBP or two-point slopes for evaluation. We aimed to identify distinct SBP responses from full times-series recorded during maximal, graded exercise and assess their clinical determinants and prognostic relevance. METHODS: In this cohort study, we analysed SBP recordings from 6107 patients (mean age, 55.4 years; 45% women) who underwent maximal cycle ergometry. Group-based trajectory modelling (GBTM) extracted sex-specific responses from absolute SBP and relative change (∆SBP) traces. Associations with clinical factors and incident major adverse cardiovascular events (MACE) were assessed using ordinal logistic regression and Cox survival analyses, respectively. RESULTS: Per sex, GBTM identified four SBP and four ∆SBP trajectories, with weak overlap between them. Higher SBP and lower ∆SBP trajectories were associated with adverse clinical profiles, including higher age and lower exercise capacity. MACE incidence was highest in the high SBP and low ∆SBP groups, but these response categories did not independently predict MACE after adjustment for resting SBP. Among patients with normotension at rest, however, a high SBP response (along with a low ∆SBP in men) was independently associated with increased MACE risk. Patients presenting both high SBP and low ∆SBP consistently conferred the highest MACE risk. CONCLUSIONS: Time-series analysis of SBP measurements during graded exercise revealed distinct response patterns with value for MACE prediction, particularly in normotensive individuals. Integrating such analyses into exercise testing may refine cardiovascular risk stratification.