Blood pressure response to bicycle exercise testing in athletes: what is 'normal'?

I t is common medical thinking that the combination of being involved in sports activities, regular exercise training and a healthy lifestyle would result in a lower incidence of hypertension and cardiovascular hard events. Fagard summarized all available published evidence and concluded that training for three to five times per week during 30–60 min per session at an intensity of about 40–50% of net maximal exercise performance appeared to be effective with regard to blood pressure (BP) reduction [1]. The former may hold true in the population at large but there has always been a vivid debate in literature on the validity of that claim in higher intensity training and even more for highly trained endurance athletes. It is justified by the common belief that increased BP is the first-in-line revealed abnormality in preparticipation cardiac screening of athletes. In the meta-analysis of 34 studies by Berge et al. [2], the reported prevalence of hypertension in athletes ranged from 0 to 83% in heavy weightlifters. As expected, the prevalence of left ventricular (LV) hypertrophy in trained individuals increased with their BP level but the mechanistic issue definitely remains a matter of debate. The interested reader will find an in-depth discussion of the topic in the ‘Recommendations for Echocardiography in Hypertension’ by Marwick et al. [3]. A typical example of a sport discipline at high risk of attaining high BP response and developing hypertension is American-style football with even substantial higher risk for their linemen [4]. However, reports in other less demanding disciplines clearly counterbalanced the concept of accrued risk of hypertension by high-intensity sports activities. For instance, a recent cross-sectional survey in a large European cohort (>2000) of competitive athletes (not including any American