Sex differences in systolic blood pressure response to exercise testing: a real-world clinical analysis

The American Heart Association recommends sex-specific thresholds for defining exaggerated systolic blood pressure response to exercise (ESBPR), primarily based on data from young healthy populations. However, their applicability and the sex differences in systolic blood pressure (SBP) response to exercise in real-world clinical settings remain unclear. We conducted a cross-sectional study of 44 418 adults (40.6% female) with a mean age of 49, who underwent treadmill exercise testing at Fuwai Hospital from 2016-2022. ESBPR was defined as peak SBP during exercise >= 210 mmHg for males and >= 190 mmHg for females. Multivariate regression models stratified by sex were used to explore whether sex modifies age-related patterns in SBP response to exercise. ESBPR was over five times more prevalent in females than males (10.1 vs. 1.9%, P < 0.001). While the mean, 90th, and 95th percentiles of peak SBP were at least 12 mmHg higher in males than females in younger age groups (18-44), the gap narrowed to less than 4 mmHg in older age groups (>= 45). Stratified multivariate analysis revealed that age was a strong predictor of ESBPR in females but not in males. Using age >= 51 as a proxy for menopause, females older than 51 had significantly higher odds of ESBPR compared to younger females (adjusted OR: 1.904, 95% CI: 1.683-2.155, P < 0.001). Our findings reveal that females and males display distinct age-related patterns in SBP response to exercise. The lower threshold for females may disproportionately classify postmenopausal females as abnormal.