title: Low exercise blood pressure and risk of cardiovascular events and all-cause mortality: systematic review and meta-analysis.
abstract: OBJECTIVE
  The independent prognostic significance of abnormally low systolic blood pressure (SBP) during exercise stress testing (LowExBP) across different clinical and exercise conditions is unknown. We sought by systematic review and meta-analysis to determine the association between cardiovascular/all-cause outcomes and LowExBP across different patient clinical presentations, exercise modes, exercise intensities and categories of LowExBP.
  
  
  METHODS
  Seven online databases were searched for longitudinal studies reporting the association of LowExBP with risk of fatal and non-fatal cardiovascular events and/or all-cause mortality. LowExBP was defined as either: SBP drop below baseline; failure to increase >10 mmHg from baseline or; lowest SBP quantile among reporting studies.
  
  
  RESULTS
  After review of 13,257 studies, 19 that adjusted for resting SBP were included in the meta-analysis, with a total of 45,895 participants (average follow-up, 4.4 ± 3.0 years). For the whole population, LowExBP was associated with increased risk for fatal and non-fatal cardiovascular events and all-cause mortality (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.59-2.53, p < 0.001). In continuous analyses, a 10 mmHg decrease in exercise SBP was associated with higher risk (n = 9 HR: 1.13, 95% CI: 1.06-1.20, p < 0.001). LowExBP was associated with increased risk regardless of clinical presentation (coronary artery disease, heart failure, hypertrophic cardiomyopathy or peripheral artery disease), exercise mode (treadmill or bike), exercise intensity (moderate or maximal), or LowExBP category (all p < 0.05). However, bias toward positive results was apparent (Eggers test p < 0.001 and p = 0.009).
  
  
  CONCLUSIONS
  Our data show that irrespective of clinical or exercise conditions, LowExBP independently predicts fatal and non-fatal cardiovascular events and all-cause mortality.
authors.affiliation: Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia; School of Human Life Sciences, University of Tasmania, Launceston, Tasmania, Australia.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Barlow
authors.affiliation: Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia.
authors.forename: Petr
authors.initials: P
authors.lastname: Otahal
authors.affiliation: Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia.
authors.forename: Martin G
authors.initials: MG
authors.lastname: Schultz
authors.affiliation: School of Human Life Sciences, University of Tasmania, Launceston, Tasmania, Australia.
authors.forename: Cecilia M
authors.initials: CM
authors.lastname: Shing
authors.affiliation: Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia. Electronic address: James.Sharman@menzies.utas.edu.au.
authors.forename: James E
authors.initials: JE
authors.lastname: Sharman
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology*; D015444:Exercise; D005080:Exercise Test; D005260:Female; D006801:Humans; D007022:Hypotension / Q000150:complications* / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D012044:Regression Analysis; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Cardiovascular disease; Exercise; Hypotension; Low blood pressure; Prognosis