Reference Values for Exercise Systolic Blood Pressure in 12- to 17-Year-Old Adolescents

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Normative values and a new predicted model of exercise blood pressure in young athletes

OBJECTIVES

Assessing the systolic and diastolic blood pressure during acute physical exertion can allow the discovery of many cardiovascular diseases even at a young age. However, this response depends on the age, sex of the subject, and the modality of the graded exercise test. This study aims to provide sex-and age-related normative values of peak and recovery blood pressure performance and to develop a predicted model of systolic and diastolic blood pressure peak in young athletes.

DESIGN

Retrospective-study.

METHODS

We analyzed 8224 young athletes (5516 males and 2708 females) aged between 8 and 18. Anthropometric and blood pressure parameters related to the effort are reported. Then, according to sex, graded exercise test modality, and age were calculated 1) the fifth, tenth, fiftieth, ninetieth, and ninety-fifth percentiles for the systolic and diastolic blood pressure at peak and after 1 min of recovery and 2) predictive equations of systolic and diastolic blood pressure at the peak.

RESULTS

Younger athletes show lower peak blood pressure values, gradually increasing as they age. Males showed higher peak systolic blood pressure values starting at 12-13 years on the cycle ergometer and 10-11 years on the treadmill, while there was no difference in peak diastolic blood pressure values.

CONCLUSIONS

Sex, age, and the specificity of the movement performed must be considered in assessing the blood pressure response in the young population. In addition, providing reference values and predictive equations of blood pressure response to acute physical exertion may allow for a better functional assessment of young athletes.

Blood pressure response to exercise in children and adolescents

Blood pressure changes during exercise are part of the physiological response to physical activity. Exercise stress testing can detect an exaggerated blood pressure response in children and adolescent. It is applied for certain clinical conditions, but is also commonly used as part of the assessment of athletes. The interpretation of blood pressure values in response to exercise during childhood and adolescence requires appropriate reference data. We discuss the available reference values and their limitations with regard to device, exercise protocol and normalization. While the link between an exaggerated blood pressure response and cardiovascular events and mortality has been demonstrated for adults, the situation is less clear for children and adolescents. We discuss the existing evidence and propose that under certain circumstances it might be reasonable to have children and adolescents undergo exercise stress testing as a rather non-invasive procedure to add additional information with regard to their cardiovascular risk profile. Based on the existing data future studies are needed to extend our current knowledge on possible links between the presence of certain clinical conditions, the detectability of an exaggerated blood pressure response during childhood and adolescence and the risk of developing cardiovascular morbidity and mortality in later life.

Blood pressure response to dynamic exercise testing in adolescent elite athletes, what is normal?

BACKGROUND

In general, only few studies are dedicated to blood pressure behavior under physical stress in children and adolescents. Even less is published about the blood pressure behavior of young high-performance athletes on the ergometer. For this reason, we evaluated the blood pressure behavior under stress compared to non-athletes in a large collective (n = 739) of young high-performance athletes (age 10-20 years, mean 15.8 years, male 442, female 297) of different sports. A complete echocardiographic examination was available in all athletes.

RESULT

Regardless of gender, the young competitive athletes achieved significantly higher maximum blood pressure values than investastigated populations from previous studies. Based on the data obtained, blood pressure percentiles are now defined explicitly for junior athletes across sports as well as age- and gender-dependent, which did not exist in this form of normal values for the special clientele of young competitive athletes. The echocardiographic examinations demonstrated stress-induced cardiac adaptation adaptations in the majority of athletes, which thus correlate with the comparatively higher stress blood pressures compared to non-athletes.

CONCLUSION

For the first time, blood pressure percentiles for exercise tests on the ergometer for age groups and gender in high performance athletes are defined based on a comparatively large collective of young competitive athletes. Upper limits were determined, in particular for systolic blood pressure under stress, and categorized according to gender and age. Performance diagnosticians and physicians are now enabled to make a more accurate assessment of the corresponding blood pressure regulation of young athletes under exercise conditions.

Normative blood pressure response to exercise stress testing in children and adolescents

Objective

To describe normative values for blood pressure (BP) response to maximal exercise in children/adolescents undergoing a treadmill stress test.

Methods

From a retrospective analysis of medical records, patients who had undergone a Bruce protocol exercise stress test, with (1) normal cardiovascular system and (2) a body mass index percentile rank below 95% were included for analysis. Sex, age, height, weight, resting and peak heart rate, resting and peak systolic blood pressure (SBP), test duration, stage of Bruce protocol at termination, reason for undergoing the test and reason for termination of test were collected. Percentiles for exercise-induced changes in SBP were constructed by age and height for each sex with the use of quantile regression models.

Results

648 patients with a median age of 12.4 years (range 6–18 years) were included. Typical indications for stress testing were investigation of potential rhythm abnormalities, syncope/dizziness and chest pain and were deemed healthy by an overseeing cardiologist. Mean test duration was 12.6±2.2 min. Reference percentiles for change in SBP by sex, age and height are presented.

Conclusion

The presented reference percentiles for the change in SBP for normal children and adolescents will have utility for detecting abnormally high or low BP responses to exercise in these age groups.

Blood Pressure Response to Treadmill Cardiopulmonary Exercise Test in Children with Normal Cardiac Anatomy and Function

OBJECTIVES

To describe blood pressure (BP) responses during cardiopulmonary exercise testing (CPET) and propose criteria for abnormal BP responses in children with normal hearts.

STUDY DESIGN

Treadmill CPET data of children <18 years with normal hearts were retrospectively analyzed to evaluate BP responses to exercise at the Children's Hospital of Michigan over an 8-year period (2011-2018).

RESULTS

Our cohort included 1085 children (boys, 59%) aged 7-17 years. Analysis of variance for systolic BP at peak exercise (peak SBP) and SBP change (Δ) showed significant age and sex effects and age-sex interaction effects (P < .01). In the multiple linear regression model (P < .001, R square 0.298, standard error of the estimate 17.15), peak SBP (mm Hg) was predicted as 132.27 + 1.37 × age (years) + (3.31 × age (years) - 31.88) × sex [boys 1, girls 0]. The following criteria for abnormal BP responses in children were proposed: hypertensive BP response was defined by peak SBP with a 90% CI upper limit of reference values based on age and sex, and blunted BP response as ΔSBP <10 mm Hg for aged 7-11 years, <20 mm Hg for boys aged 12-17 years, and ΔSBP <10 mm Hg in girls.

CONCLUSIONS

BP responses to treadmill CPET depend on age and sex in children with normal hearts. The proposed criteria for abnormal BP responses in children during CPET will need to be verified in a large pediatric cohort.

Epinephrine stress testing during cardiac catheterization in patients with aortic coarctation

BACKGROUND

The severity of aortic coarctation (CoA) may be underestimated during cardiac catheterization. We aimed to investigate whether epinephrine stress testing improves clinical decision making and outcome in CoA.

METHODS

We retrospectively evaluated CoA patients >50 kg with a peak systolic gradient (PSG) ≤20 mm Hg during cardiac catheterization who underwent epinephrine stress testing. Subsequent interventional management (stenting or balloon dilatation), complications, and medium-term clinical outcome were assessed.

RESULTS

Fifty CoA patients underwent cardiac catheterization with epinephrine stress testing. Patients with a high epinephrine PSG (>20 mm Hg; n = 24) were younger and more likely to have a hypertensive response to exercise compared to patients with a low epinephrine PSG (≤20 mm Hg; n = 26). In total, 21 patients (88%) with a high epinephrine PSG underwent intervention, and 20 patients (77%) with a low epinephrine PSG were treated conservatively. After a mean follow-up of 25 ± 18 months, there was a lower prevalence of hypertension in patients with a high epinephrine PSG who underwent intervention compared to patients with a low epinephrine PSG treated conservatively (19% vs. 76%; P = .001). In a multivariate model, intervention was independently associated with a 14.3-mm Hg reduction in systolic blood pressure (P = .001) and a decrease in the use of antihypertensive agents.

CONCLUSIONS

In CoA patients with a low baseline PSG but high epinephrine PSG, percutaneous intervention is associated with a substantial reduction in systemic blood pressure and the use of antihypertensive medication. Accordingly, epinephrine stress testing may be a useful addition in the evaluation of CoA.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Reference values for resting and post exercise hemodynamic parameters in a 6-18 year old population

This database is the first large dataset of haemodynamic changes of normal-weight pupils during a field exercise test. Here, we present a dataset for anthropometric and hemodynamic parameters measured both during relaxation and after exercise containing 1,173,342 data segments from 65,345 acquisition points of 10,894 normal weight subjects, covering an age range of 6–18 years collected in a course of 12 years. Data acquisition was carried out under standardised measuring conditions and specifications. Hemodynamic parameters were measured in the normal-weight population with a new and simple Fit-Test which could facilitate new projects worldwide to study and compare cardiovascular fitness.

Measurement(s)	anthropometric measurement • heart rate • blood pressure
Technology Type(s)	anthropometric analysis • Cardiac Monitoring
Factor Type(s)	age
Sample Characteristic - Organism	Homo sapiens

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.11417481

A systematic review and meta-analysis of exercise and exercise hypertension in patients with aortic coarctation

Exercise hypertension is a common occurrence among individuals with aortic coarctation. Although exercise is known to be beneficial among the general population, the risks and benefits of exercise among those with aortic coarctation are less clear. This systematic review evaluates the benefits and risks of exercise for persons with aortic coarctation. Electronic databases were systematically searched (that is, MEDLINE and EMBASE) and key reviews cross-referenced to identify articles for inclusion. Original research articles reporting exercise among individuals with aortic coarctation were included. From 2608 individual citations, 68 eligible articles were identified. Aerobic exercise stress tests were found to be useful for determining exercise hypertension experiences post-surgical repair (N=5), and other long-term secondary findings (N=3). Experiences of exercise hypertension were associated with abnormal cardiac and/or aortic geometry and cardiac function (N=7). Exercise capacity was generally found to be similar to non-aortic coarctation controls post surgery (N=6). Exercise hypertension was experienced by 27% of participants, including 10% of adults and 43% of children/youth. Individuals who experience exercise hypertension experience greater increases in systolic blood pressure with exercise. No investigations identified evaluated forms of exercise other than aerobic stress tests and no exercise training programs have been conducted to date. Exercise stress tests can be valuable in this population for determining exercise hypertension, especially in the year post-surgical repair. Additional research is urgently needed to accurately assess the benefits and risks of exercise and exercise hypertension, and applicability of exercise restrictions for this population.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.