What is the definition of a hypertensive response to treadmill stress testing?

Definition of Hypertensive Response to Treadmill Stress Testing

A hypertensive response to exercise is defined as a peak systolic blood pressure ≥210 mm Hg in men and ≥190 mm Hg in women, or a peak diastolic blood pressure ≥90 mm Hg (with some sources using >10 mm Hg rise above resting or absolute value of 90 mm Hg). 1

Systolic Blood Pressure Criteria

The most widely accepted and guideline-supported definitions for exaggerated systolic blood pressure response include:

• Peak systolic BP ≥210 mm Hg for men 1
• Peak systolic BP ≥190 mm Hg for women 1
• Systolic BP >250 mm Hg represents a relative indication for test termination 1

These thresholds are based on the 2013 American Heart Association Exercise Standards, which represent the most authoritative guideline on this topic. 1

Diastolic Blood Pressure Criteria

For diastolic blood pressure, a hypertensive response is characterized by:

• Rise in diastolic BP >10 mm Hg above resting value during exercise 1
• Absolute diastolic BP value of ≥90 mm Hg during exercise 1
• Diastolic BP >115 mm Hg represents a relative indication for test termination 1

The diastolic criteria are considered abnormal and may predict increased likelihood of coronary artery disease. 1

Alternative Definitions in Clinical Practice

Recent literature has identified additional definitions that may be clinically relevant:

• Peak systolic BP >214 mm Hg in normotensive subjects has been associated with increased long-term risk of developing hypertension 1
• Systolic BP between 160-200 mm Hg at 100 watts of workload (submaximal exercise definition) 2
• Blood pressure response corrected for metabolic equivalents (METs) may provide more nuanced assessment, with values >11.3 mmHg/MET representing the top tertile of responders 3

However, these alternative definitions are research-based and not yet incorporated into major clinical guidelines. 3, 2

Recovery Phase Considerations

Blood pressure behavior during recovery also provides important prognostic information:

• Failure of systolic BP to fall during recovery or a rise relative to maximal exercise value predicts increased risk of death 1
• Elevated systolic or diastolic BP at 3 minutes into recovery is associated with increased long-term risk of hypertension 1
• Systolic BP >150 mm Hg at 2-minute recovery has been linked to increased cardiovascular risk 4

Clinical Significance and Pitfalls

Important caveats to recognize:

• An exaggerated systolic BP response indicates increased risk for future hypertension, left ventricular hypertrophy, and cardiovascular events, but does not necessarily indicate current coronary artery disease 1
• The definition applies to maximal exercise testing, not submaximal protocols 1
• Athletes may have higher thresholds (220/210 mm Hg) due to greater total workload capacity 2
• Resting BP >130/80 mm Hg significantly increases likelihood of manifesting hypertensive response during exercise, independent of hypertension diagnosis 5
• The prognostic significance of hypertensive response in women remains somewhat controversial, with conflicting data on whether it predicts future cardiovascular events 1

Practical Application

When interpreting exercise stress tests, apply these thresholds systematically:

1. Measure BP at rest, peak exercise, and during recovery (at least at 2-3 minutes) 1
2. Compare peak values to sex-specific thresholds (≥210 mm Hg men, ≥190 mm Hg women for systolic) 1
3. Assess diastolic response (>10 mm Hg rise or ≥90 mm Hg absolute) 1
4. Evaluate recovery patterns for failure to decline appropriately 1
5. Consider terminating test if systolic BP >250 mm Hg or diastolic BP >115 mm Hg 1

The 2013 American Heart Association guidelines provide the most authoritative and clinically applicable definitions, which should be used as the standard in routine practice. 1