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

Journal of Human Hypertension (2025)Cite this article

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Abstract

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.

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Fig. 1
Fig. 2
Fig. 3: Adjusted odds ratios of age for exaggerated systolic blood pressure response, stratified by sex.

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Public data is not applicable to this study. Study data are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors express our gratitude to all the participants who took part in the treadmill exercise tests in our study. The authors also greatly appreciate the dedicated staff of the Department of Cardiac Function Test Center, Fuwai Hospital for their expertise and commitment in conducting the treadmill exercise tests with precision and care.

Funding

This research was supported by the National High Level Hospital Clinical Research Funding (2022-GSP-GG-014).

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Authors and Affiliations

  1. Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China

    Shengming Li, Chen He, Yan Yao, Xiaofei Li & Xiaohan Fan

  2. Department of Cardiac Function Test Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China

    Tianjing Zhang, Jia He, Fang Liu & Xiaohan Fan

  3. Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China

    Rutai Hui

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  1. Shengming Li
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Contributions

Shengming Li: Conceptualization, Formal analysis, Methodology, Writing—original draft. Tianjing Zhang: Formal analysis, Writing—original draft. Jia He: Data collection. Chen He: Data collection. Fang Liu: Formal analysis. Yan Yao: Conceptualization, Supervision. Xiaofei Li: Data collection, Writing—review and editing. Rutai Hui: Writing—review and editing. Xiaohan Fan: Conceptualization, Formal analysis, Data collection, Funding acquisition, Methodology, Project administration, Supervision, Writing—review and editing.

Corresponding authors

Correspondence to Xiaofei Li or Xiaohan Fan.

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The authors declare no competing interests.

Ethical approval

This cross-sectional study was approved by the Institutional Review Board of Fuwai Hospital, which granted a waiver of informed consent for research purposes, as the data were obtained from tests performed as part of routine clinical care rather than exclusively for research.

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Li, S., Zhang, T., He, J. et al. Sex differences in systolic blood pressure response to exercise testing: a real-world clinical analysis. J Hum Hypertens (2025). https://doi.org/10.1038/s41371-025-01037-1

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