Invited authors’ reply
Authors’ reply to ‘Reference values for
systolic blood pressure at upright bicycle
exercise tests’ by Alfred Hager
Kristofer Hedman
1, Thomas Lindow
2, Viktor Elmberg
3,
Lars Brudin
4and Magnus Ekstr
€om
5We are pleased by the attention and acknowledgement given by Professor Hager1to our article regarding ref-erence values for systolic blood pressure (SBP) during bicycle exercise testing, recently published in the European Journal of Preventive Cardiology.2 Although none of the authors of our article is a native German speaker, we appreciate the reference provided by Professor Hager to the article published in a German sports medicine journal in 1984, by Heck et al.3 With a slight risk of misinterpreting the data presented in German by Heck et al.,3we feel reassured in our findings that: (a) SBP increases linearly with increasing workload in both men and women; and (b) the linear increase is similar across ages, although slightly steeper in older individuals in addition to start-ing from a higher baseline level (i.e. SBP at rest) at older age.
Professor Hager suggests a rule of thumb in individ-uals less than 40 years of age, that the predicted SBPmax
should be approximately 0.33 mmHg/Watt plus the SBP measured at rest, before exercise.1We agree that this seems like a feasible and reasonable approach, and could be adopted clinically as long as the measurement of SBP at rest is well standardised, the SBPmax
mea-surement is obtained at or very close to the maximal workload, and different reference values are used for individuals aged over 40 years. However, the most important question is probably not the predicted SBPmax per se, but rather when the measured SBPmax
or the SBP/Watt slope exceeds the predicted value to an extent that is clinically relevant. For this purpose, we suggest to either use the sex and age-specific upper 90th or 95th percentiles provided in the appendices of our article, or the multivariable regression equations in Table 2.2 As Professor Hager points out, the latter is probably preferable for research purposes and requires implementation in exercise testing software or the use of our supplementary Excel sheet to be feasible in clin-ical practice.
Future research is warranted to evaluate these reference values from a prognostic point of view, as previously done for the SBP/metabolic equivalent (MET) slope in treadmill testing.4
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
1. Hager A. Reference values for systolic blood pressure at upright bicycle exercise tests. Eur J Prev Cardiol 2020. Epub ahead of print, DOI: 10.1177/ 2047487320922924.
2. Hedman K, Lindow T, Elmberg V, et al. Age- and gender-specific upper limits and reference equations for workload-indexed systolic blood pressure response during bicycle ergometry. Eur J Prev Cardiol. Epub ahead of print 10 March 2020 DOI: 10.1177/2047487320909667.
1Department of Clinical Physiology in Link€oping, and Department of Health, Medicine and Caring Sciences, Link€oping University, Sweden 2Department of Clinical Physiology, V€axj€o Central Hospital, Sweden 3
Department of Clinical Physiology, Blekinge Hospital, Sweden 4
Department of Clinical Physiology, Kalmar County Hospital, Sweden 5
Department of Clinical Sciences Lund, Lund University, Sweden Corresponding author:
Kristofer Hedman, Department of Clinical Physiology in Link€oping, and Department of Health, Medicine and Caring Sciences, Link€oping University, Link€oping, Sweden.
Email: Kristofer.Hedman@liu.se
European Journal of Preventive Cardiology
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! The European Society of Cardiology 2020
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3. Heck H, Rost R and Hollmann W. Standard blood pres-sure values during ergometric bicycle tests. Deutsche Zeitschrift fu¨r Sportmedizin 1984; 35: 243–249.
4. Hedman K, Cauwenberghs N, Christle JW, et al. Workload-indexed blood pressure response is superior to
peak systolic blood pressure in predicting all-cause mor-tality. Eur J Prev Cardiol, Epub ahead of print 30 September 2019. DOI: 10.1177/2047487319877268.
