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Diagnostic accuracy of different exercise blood pressure metrics in identifying hypertension on 24-h ambulatory blood pressure monitoring in athletes

Journal of Human Hypertension volume 40, pages 10–17 (2026)Cite this article

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Abstract

Exercise blood pressure (BP) metrics have been promoted as a means of identifying latent or mild hypertension in athletes. We evaluated the diagnostic accuracy of four exercise BP metrics to diagnose hypertension, defined by 24-h ambulatory BP monitoring (ABPM) as mean ≥130/80 mmHg, daytime ≥135/85 mmHg and/or nighttime ≥120/70 mmHg. Fifty-four endurance-trained athletes (48 [IQR 24–58] years, 67% male) underwent exercise testing with serial BP measurements and 24-h ABPM. Exaggerated exercise BP (EEBP) was defined as exceeding a threshold for any of the four metrics: 1) maximal systolic BP (SBPmax) using published cut-offs; SBPmax ≥ 220 mmHg and ≥200 mmHg in males and females, respectively, 2) SBP/Workload-slope, 3) SBPmax/Workload-ratio, 4) SBP at 2 Watts/kg. Receiver operating characteristic (ROC) curve analysis and Youden’s Index determined optimal cut-offs and diagnostic performance. Twelve of 54 (22%) athletes met criteria for hypertension. SBPmax was reasonably sensitive for identifying hypertension (83% identified) but demonstrated poor specificity (62% of non-hypertensives misclassified), with an area under the ROC-curve (AUC) of 0.63. An EEBP cut-off of SBP > 176 mmHg at 2 Watts/kg had the best diagnostic performance with 100% sensitivity, moderate specificity of 62%, and AUC of 0.79. Other metrics, incorporating exercise BP and workload, SBPmax/Workload-ratio and SBP/Workload-slope, had moderate diagnostic utility (AUC = 0.71 and 0.67, respectively). In endurance athletes, exercise BP metrics demonstrated modest and variable diagnostic accuracy for identifying hypertension on 24-h ABPM. Assessment of SBP at a relative submaximal workload provided acceptable diagnostic accuracy while reducing overdiagnosis associated with published SBPmax thresholds.

Graphical Abstract – Created in BioRender. La Gerche, A. (2025) https://BioRender.com/undefined Abbreviations: SBP, systolic blood pressure; ABPM, ambulatory blood pressure monitoring.

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Fig. 1: Twenty-four-hour ambulatory blood pressure results in 54 athletes.
Fig. 2: Maximal exercise systolic blood pressure (SBPmax) >250 mmHg and corresponding 24-h ambulatory SBP in a subset of athletes (n = 13).
Fig. 3: Comparative diagnostic performance of exercise blood pressure metrics for identifying hypertension.

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The data underlying this article will be shared on reasonable request with the corresponding author.

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Funding

KJ is supported through an Australian Government Research Training Program Scholarship https://doi.org/10.82133/C42F-K220. PD’A is supported by a Royal Australian College of Physicians Research Entry Scholarship (ID: 2023RES00039), The National Health and Medical Research Council Postgraduate Scholarship (ID: 2031119) and a Heart Foundation PhD Scholarship (ID: 107659). AM is supported by The National Health and Medical Research Council Postgraduate Scholarship (ID: 2030942). ALG is supported by a National Health and Medical Research Council of Australia Investigator Grant (APP 2027105). Y.B. received funding through the Flanders Research Foundation (FWO), file number T004420N.

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Authors and Affiliations

  1. Exercise and Nutrition Research Program, The Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia

    Kristel Janssens & Evelyn B. Parr

  2. Heart and Exercise Research Trials laboratory, St. Vincent’s Institute of Medical Research, Melbourne, VIC, Australia

    Kristel Janssens, Stephen J. Foulkes, Paolo D’Ambrosio, Amy M. Mitchell, Stephanie J. Rowe, Youri Bekhuis, Luke Spencer & Andre La Gerche

  3. Integrated Cardiovascular Exercise Physiology and Rehabilitation Lab, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada

    Stephen J. Foulkes

  4. Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia

    Paolo D’Ambrosio, Amy M. Mitchell, Stephanie J. Rowe, Luke Spencer & Andre La Gerche

  5. Department of Cardiology, John Hunter Hospital, Newcastle, NSW, Australia

    Paolo D’Ambrosio

  6. Department of Cardiology, St. Vincent’s Hospital, Fitzroy, VIC, Australia

    Stephanie J. Rowe & Andre La Gerche

  7. Faculty of medicine and life Sciences, UHasselt, Biomedical Research Institute, Diepenbeek, Belgium

    Youri Bekhuis & Guido Claessen

  8. Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium

    Youri Bekhuis

  9. Department of Pharmacology, Monash University, Melbourne, VIC, Australia

    Geoffrey A. Head

  10. Department of Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium

    Hein Heidbuchel

  11. Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium

    Hein Heidbuchel

  12. HEART lab, Victor Chang Cardiovascular Research Institute, Sydney, NSW, Australia

    Andre La Gerche

Authors
  1. Kristel Janssens
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  2. Stephen J. Foulkes
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  3. Paolo D’Ambrosio
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  12. Andre La Gerche
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Contributions

KJ, ALG: conceptualization; KJ, SF, ALG: formal analysis; KJ, AM: investigation; KJ, SF, ALG: methodology; KJ, AM: project administration; ALG, SF, EP: supervision; KJ, SF, ALG: writing-original draft; EP, GC, HH, GH, AM, LS, SR, YB, PD’A: writing-review and editing.

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Correspondence to Kristel Janssens.

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This study was conducted following the Declaration of Helsinki and was approved by the Alfred Hospital Ethics Committee (333/15 and 484/16). The authors confirm that patient informed consent forms have been obtained for this article.

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Janssens, K., Foulkes, S.J., D’Ambrosio, P. et al. Diagnostic accuracy of different exercise blood pressure metrics in identifying hypertension on 24-h ambulatory blood pressure monitoring in athletes. J Hum Hypertens 40, 10–17 (2026). https://doi.org/10.1038/s41371-025-01089-3

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