Vol.2, No.8, 890-896 (2010)
doi:10.4236/health.2010.28132
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
HEALTH
Independent relationships of systolic blood pressure
recovery with cardiovascular variables in healthy
urban adults
Ganesan Kathiresan*, Ganesh Pandian Subramanian, Venkatesan Rajagopal,
Vijayasankar Venkatasubramanian
Department of Physiotherapy, School of Allied Health, Masterskill University College, Sabah, Malaysia;*Corresponding Author:
Received 8 May 2010; revised 26 May 2010; accepted 27 May 2010.
ABSTRACT
Background: In the recent years, various stud-
ies on clinical evaluation of systolic blood pre-
ssure recovery (SBPR) as a prognostic tool for
diagnosing cardiovascular abnormalities in pa-
tients undergoing exercise test has become a
subject of an interest. The Purpose of this study
is to evaluate the independent relationships of
systolic blood pressure recovery (SBPR) with
Cardiovascular Variables in healthy Urban adults.
Methodology: Normotensive subjects (157 nos.)
of both the genders were performed cycle er-
gometer exercise at progressive incremental
workloads until subjects reached 80% of their
age-predicted maximum HR. Blood pressure
(BP) was measured before exercise, during ex-
ercise, immediately after exercise and subse-
quently at 2-minute intervals until recovery to
baseline. The ratio of third-minute SBP relative
to first-minute post exercise SBP was used as
the SBPR variable. Results: Our results indi-
cated independent correlations (p < 0.05) be-
tween SBPR and age, resting HR, physical ac-
tivity and cigarette smoking (r = 0.473; 0.192;
–0.262; 0.102 respectively in males and r = 0.113;
0.315; –0.637; 0.104 respectively in females).
BMI associated positively (r = 0.106; p < 0.01)
with SBPR in males but not in females (r = 0.092),
while WC was predictive of SBPR in females (r =
0.212; p < 0.01) but not in males (r = 0.005). Age
in men and physical activity in females were the
strongest predictors of SBPR. Conclusion: The
present findings in which SBPR is associated
with risk factors of cardiovascular abnormalities
strengthen the previously reported significance
of SBPR after exercise test as a prognostic tool
for the evaluation of cardiovascular abnormali-
ties. Additionally, it may help clinicians to define
and interpret the mechanisms behind changes
in post exercise SBP responses in adults in fu-
ture investigations.
Keywords: Cycle Ergometer Exercise; Cardiovascular
Variables; Systolic Blood Pressure Recovery
1. INTRODUCTION
In the recent years, various studies on clinical evaluation
of systolic blood pressure recovery (SBPR) as a prog-
nostic tool for diagnosing cardiovascular abnormalities
in patients undergoing exercise test has become a subject
of an interest [1-5]. In these studies, a delay in SBPR is
correlated with an increased risk of cardiovascular dis-
eases such as coronary artery disease, angina pectoris,
hypertension, acute myocardial infarction and stroke.
The SBPR is evaluated using a very useful and readily
obtainable parameter, the third minute SBP ratio, which
is defined as the ratio of SBP in 3 min of recovery rela-
tive to either the peak-exercise SBP [6], or SBP in 1 min
of recovery [4]. However, the third-minute SBP relative
to 1 min post-exercise SBP (SBPR2) is often preferred to
the third- minute SBP ratio relative to peak-exercise SBP
(SBPR1) because it has the advantage of the accuracy of
blood pressure measurement [4], since both SBPs can be
obtained only in the recovery state. This avoids the in-
accuracy associated with exercise blood pressure meas-
urement [7]. A value of the third-minute SBP ratio rela-
tive to 1 min post-exercise SBP greater than 1.0 is con-
sidered a delayed SBP recovery [4].
Since delayed SBPR is a risk factor for cardiovascular
diseases, there is a need to evaluate the relationships
between SBPR and factors previously associated with
cardiovascular events in order to provide better basis for
defining and interpreting changes in post-exercise SBP
responses to physical stress in future investigations. Age,
obesity index, resting heart rate (HR), physical fitness,
and cigarette smoking have been associated with SBP

G. Kathiresan et al. / HEALTH 2 (2010) 890-896
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response during exercise [8], and reported to be risk fac-
tors for hypertension, coronary artery disease and other
cardiovascular events [8,9]. In contrast, post-exercise
SBPR has been shown to indicate age and gender dif-
ferences and related to physical fitness and HR during
recovery [3,10,11]. However, no study to our knowledge
has associated SBPR with obesity indices (body mass
index (BMI) and waist circumference), resting HR or
cigarette smoking. Similarly, no study has compared the
predictive strength of the above variables on SBPR.
In the present study, we demonstrated whether age,
sex, BMI, waist circumference, resting HR, physical
activity, and cigarette smoking are independently related
to post exercise SBPR or not, in Malaysian adults who
performed Treadmill exercise. In addition, we deter-
mined which of these variables best predicts changes in
SBPR.
2. METHODOLOGY
One hundred and fifty seven apparently healthy, nor-
motensive subjects of both the genders(62 were males
and 95 were females), apparently healthy, normotensive
subjects between the ages of 18 to 66 years had selected
from students and staff of Masterskill college of Nursing
and Health sciences, Sabah, Malaysia. Subjects were
randomly selected based on the results of a structured
health and lifestyle screening questionnaire, physical
examination, morphometric measurements and medical
history. Information on cigarette smoking was obtained
by verbal report from the subjects. Subjects were classi-
fied as smokers or nonsmokers. Physical activity statuses
of the subjects were evaluated using the international
physical activity questionnaire (IPAQ) for adults [3]. The
IPAQ comprises a set of 4 questionnaires which are used
to assess the physical behaviors of participants at differ-
ent times and places and the time spent being physically
active in the last 7 days. The reliability and validity of
IPAQ has been tested and results suggest that it is an
acceptable measure of physical activity in adults [3].
Based on the IPAQ scores, subjects were classified as
inactive, moderately active and highly active. These
scores were recorded as categorical data (inactive = 1;
moderately active = 2; highly active = 3).
2.1. Inclusion Criteria
1) Ability of a subject to perform a vigorous cycle er-
gometer exercise at 80% of age–predicted maximum HR
intensity.
2) No prior history of unstable cardiovascular, periph-
eral vascular and respiratory disease, malignancy, and
orthopedic or musculoskeletal disorders.
3) Subjects should be non obese and non diabetics.
4) Subjects should have normal blood pressure (BP)
and HR.
5) Not taking medications that could affect cardio-
vascular functions
6) Not menstruating at the time of test if female.
Subjects were informed (written and oral) of the ex-
perimental procedures and their consents were obtained
before participation.
2.2. PROCEDURE
2.2.1 Exercise Test
The exercise tests were carried out in a well-ventilated
room, using a mechanically braked cycle ergometer.
With the ergometer cycling protocol, it is easy to obtain
reliable blood pressure measurements especially during
recovery period. The cycle ergometer usually consists of
progressive incremental workloads that may have minor
effects on SBPs achieved during the exercise test [12].
Participants were instructed not to consume beverages
containing alcohol or coffee, not to eat a heavy meal, or
participate in any vigorous physical activity 24 hours
before the test. They were also properly instructed on
how to perform the exercise test with demonstrations.
The exercise protocol comprised an initial two-minute
warm up at a work load of 20 Watts, followed by a linear
increase of 20 Watts every minute until the subject
reached the targeted percentage (80%) of age-predicted
maximum HR (HR max), after which the exercise test
was terminated. The HR max was determined as HR
max = 208 minus (0.7 × age), [13]. The rating of per-
ceived exertion (RPE) to exercise was obtained using the
Borg’s scale [2] immediately after the exercise protocol.
2.2.2. Anthropometric Measurements
Subject’s height was measured to the nearest 0.1 cm with
the use of stadiometer with the shoulders in a relaxed
position and the arms hanging freely. Weight was meas-
ured to the nearest 0.1 kg in light clothing without shoes
using a balance scale. BMI was calculated as weight (kg)
divided by the square of the height (m2). Waist circum-
ference was measured twice to the nearest 0.1 cm using
an inelastic and flexible tape, on a horizontal plane at the
end of normal expiration with subjects lightly clothed
and standing. The mean of the two measurements was
used for subsequent analysis. Waist circumference was
measured half way between the top of the iliac crest and
the lower rib margin.
2.2.3. Blood Pressure and Heart Rate
Measurements
Resting BP and HR were measured after 10 and 15 min-
utes of rest, in a seated position and in a quiet room, one
week prior to the exercise test, using the mercury-column
sphygmomanometer and an automated upper arm-cuff

G. Kathiresan et al. / HEALTH 2 (2010) 890-896
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HR monitor (Omron Health Care Inc., Vernon Hills,
Illinois) respectively. The resting BP and HR measure-
ments were used to ascertain whether a subject had nor-
mal BP and HR or not. Immediately before the exercise
test, subject’s pre-exercise BP and HR were also meas-
ured twice (after 10 and 15 minutes of rest) when sitting
on the cycle ergometer. During the exercise, BP was
measured at two-minute intervals and during the last
minute of exercise, as soon as the subject reached his or
her targeted HR. Heart rate on the other hand, was
measured continuously every minute until the subject
attained the targeted HR equivalent to the 80% HR max
intensity. The peak-exercise BP and HR were defined as
the highest values achieved at the termination of the ex-
ercise. Further BP measurements were done immediately
after exercise (within the first minute of recovery) and
subsequently at two-minute intervals until recovery to
pre exercise level (i.e. measurements were done at 1, 3, 5,
7,…min). During the post-exercise BP measurement,
subjects were asked to be in sitting position on the bicy-
cle without pedaling while the research personnel were
blinded to the test results at baseline and during exercise.
First and third minutes of recovery were used to express
the periods of recovery after exercise in this study, since
they were available for all subjects. We evaluated SBPR
using the ratio of third minute SBP relative to SBP at 1
min of recovery [14], calculated as 3 min post exercise
SBP divided by 1 min post-exercise SBP. We preferred
SBPR2 as our index of SBPR because both SBPs are
obtained only in the recovery state, thus avoiding the
inaccuracy associated with exercise blood pressure
measurement [15].
2.2.4. Statistical Analyses
Descriptive data are presented as means ± SD. Data
analyses between the gender groups were performed
using the independent sample t-test. Pearson’s bivariate
correlation test was used to evaluate the relationships
between SBPR2 and age, BMI, WC, resting HR, physi-
cal activity status, and cigarette smoking. Independent
relationships between SBPR2 and the predictor variables
were analyzed using multiple linear regression with the
SBPR2 as the dependent variable. All statistics were
done using SPSS for Windows (Version 16.0). Statistical
significance was set at p < 0.05.
3. RESULTS
Demographic data and baseline characteristics of sub-
jects are as presented in Table 1. The mean ages of the
subjects were 28 ± 13.95 and 27 ± 14.73 years for the
males and the females respectively. Waist circumference,
pre-exercise SBP and pre exercise DBP were signifi-
cantly higher in males than females. On the other hand,
females indicated higher resting HR than the males.
Body mass index indicated no significant difference be-
tween the genders.
Table 2 shows the exercise test characteristics of sub-
jects. Men indicated significantly higher peak-exercise
SBP, peak-exercise DBP, SBPR1, and SBPR2 than did
the women. Peak exercise HR and rating of perceived
exertion indicated no significant differences between the
genders. Changes of SBP as it falls from peak exercise to
baseline during recovery are as shown in Figure 1. At 1
minute of recovery, SBP declined to 164 mmHg for
males, and 173 mmHg for females, while at 3 minutes of
recovery, the data indicated 140 mmHg and 141 mmHg
for males and females respectively.
Table 3 shows a bivariate correlation analysis be-
tween SBPR2 and age, BMI, waist circumference, rest-
ing HR, physical activity status, and cigarette smoking in
males and females. In both gender groups, all variables
indicated significant and positive relationships with
SBPR2 except physical activity status, which was nega-
tively associated with SBPR2.
Table 4 reveals a multiple regression analysis to eva-
luate the independent relationship between SBPR2 and
age, BMI, waist circumference, resting HR, physical
activity status, and cigarette smoking in males and fe-
males. In men, all the variables except waist circumfer-
ence remained significantly predictive of SBPR2 after
adjusting for each other. In women, SBPR2 associated
significantly with all the variables except BMI. Com-
bining the data for men and women, we evaluated the
independent association between gender and SBPR. A
multiple regression analysis indicated a significant and
independent relationship between gender and SBPR2 (r
= 0.248; p < 0.001).
4. DISCUSSION
Our findings indicated that, in both genders, age, resting
HR, and cigarette smoking were independently and posi-
tively associated with SBPR, while physical activity
indicated negative association with SBPR; body mass
index, and waist circumference were predictive of SBPR
in at least one gender-specific group. Age in males and
physical activity in females were the best predictors of
SBPR. Changes in SBPR are thought to be due to
changes in systemic vascular resistance [16,17], sympa-
thetic and parasympathetic activities [12,16], and baro-
reflex sensitivity [18]. Similarly, SBPR has been re-
ported to indicate age and gender differences and related
to physical fitness and HR recovery [9,10,12]. Blunted
or delayed recovery of SBP after exercise is also associ-
ated with increased risk of cardiovascular diseases
[12,14,16, 19,20]. In the present study, age was inde-

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pendently
Table 1. Demographic and baseline characteristics of subjects.
Characteristics
Age(yrs)
Males(n = 62)
28.0 ± 13.95(18-66)
Females(n = 95)
27.0 ± 14.73(18-65)
p-Value
NS
Height(m) 1.7 ± 0.07(1.5-1.9) 1.6 ± 0.06 (1.5-1.8) < 0.001
Weight(kgs) 66.7 ± 8.48(51-87) 60.3 ± 9.05(43-86) < 0.001
BMI(Kgs/m2) 21.9 ± 8.31(18.1-28.0) 21.7 ± 7.75(18.0-27.2) NS
Waist circumference(cms) 80.4 ± 7.35(70-94) 74.8 ± 6.75(68-82) < 0.001
Pre Exercise SBP(mmHg) 120.0 ± 8.41(99-136) 118.0 ± 10.26(96-137) < 0.05
Pre Exercise DBP(mmHg) 78.0 ± 6.05(66-88) 74.0 ± 7.79(60-88) < 0.001
Resting HR (bpm) 73.0 ± 9.57(58-84) 75.0 ± 6.29(63-81) < 0.05
Data are Means ± SD and Range; Abbreviations: BMI－Body Mass Index; SBP－Systolic Blood Pressure; DBP－Diastolic Blood Pressure; HR－
Heart Rate; n－Number of Subjects; NS－Non Significant.
Table 2. Exercise Test Characteristics of Subjects.
Characteristics
Peak Exercise SBP(mmHg)
Males(n = 62)
184.0 ± 11.31(150-210)
Females(n = 95)
180.0 ± 13.00(144-197)
p-Value
< 0.001
Peak Exercise DBP(mmHg) 81.0 ± 6.00(69-91) 75.0 ± 7.62(60-90) < 0.001
Peak Exercise HR (bpm) 151.0 ± 7.75(129-156) 150.0 ± 8.89 (129-156) NS
RPE 16.8 ± 0.65(16-18) 16.8 ± 0.70(16-18) NS
SBPR1 0.76 ± 0.04(0.72-0.90) 0.74 ± 0.08(0.57-0.91) < 0.05
SBPR2 0.85 ± 0.03(0.76-0.94) 0.81 ± 0.08 (0.62-0.95) < 0.001
Data are Means ± SD and Range; Abbreviations: BMI－Body Mass Index; SBP-Systolic Blood Pressure; DBP－Diastolic Blood Pressure; HR－
Heart Rate; n－Number of Subjects; NS－Non Significant; RPE－Rated of Perceived Exertion; SBPR1－Third minute Systolic Blood Pressure rela-
tive to peak exercise; SBPR2－Third minute Systolic Blood Pressure relative to 1 minute of recovery.
Table 3. Bivariate correlation coefficients and p values for the association of predictor variables with SBPR2 in males and females.
Males Females
Characteristics Co efficient P Value Co efficient P Value
Age(yrs) 0.895 < 0.001 0.305 < 0.05
BMI(Kgs/m2) 0.747 < 0.001 0.486 0.355
Waist circumference(cms) 0.387 < 0.001 0.551 0.969
Smoking 0.620 < 0.001 0.250 < 0.001
Physical Activity –0.860 < 0.001 –0.857 < 0.001
Resting Heart Rate (bpm) 0.915 < 0.001 0.743 < 0.01
Table 4. Multiple linear regression coefficients and p values for the association of predictor variables with SBP in males and females.
Males Females
Characteristics
Co efficient P Value Co efficient P Value
Age(yrs) 0.473 < 0.001 0.113 < 0.01
BMI(Kgs/m2) 0.106 < 0.01 0.092 0.146
Waist circumference(cms) 0.005 0.823 0.212 < 0.01
Smoking 0.102 < 0.001 0.104 < 0.01
Physical Activity –0.262 < 0.001 –0.637 < 0.001
Resting Heart Rate (bpm) 0.192 < 0.01 0.315 < 0.001
and positively related to SBPR in males and females.
Age has been previously associated with blood pressure
responses [15]. Age differences have also been found in
SBPR after exercise with the older subjects indicating

G. Kathiresan et al. / HEALTH 2 (2010) 890-896
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894
slower SBP recovery than younger adults [10]. Changes
observed in blood pressure responses due to advancing
*= Significant gender difference (p < 0.001).
Figure 1. Changes of SBP during recovery periods in males
and females.
age are suggested to be due to increase in systemic vas-
cular resistance [21,22], decrease in parasympathetic
activity [8], elevated sympathetic activity [23], decline
in physical fitness [24], and reduced baro- reflex sensi-
tivity [25] in older adults. Ageing is also related to in-
creased risk of cardiovascular diseases [21,22]. These
factors as already stated above are associated with SBPR
after exercise and may help explain the independent re-
lationship observed between age and SBPR in the pre-
sent study. Overweight and obesity have been previously
related to blood pressure response during exercise [4]
but not to post exercise SBPR. Previous studies [26,27]
have consistently shown that both absolute total fat and
adipose tissue distribution are closely associated with the
risk of diabetes, hypertension, hyper lipidaemia and car-
diovascular diseases. BMI appears to be the best and
most cited index for obesity because it approximates
adiposity and fat distribution in adults [28]. It is also
considered a strong predictor of metabolic risks [29].
Recent studies have also suggested that waist circum-
ference is the best index of abdominal visceral adipose
tissue [30] and may also be the best index for predicting
cardiovascular risks [31].
The present data demonstrated independent and posi-
tive relationships between SBPR and BMI in males, and
waist circumference in females. These findings show
that an increase in level of adiposity will lead to increase
in SBPR2 (slower SBPR) and also suggest that BMI was
the better obesity index that explained variations in
SBPR in males while waist circumference best predicted
SBPR in females. Our findings concur with previous
studies which have shown that central obesity is more
closely associated with cardiovascular risks than general
obesity in women [32,33], while general obesity best
predicts cardiovascular risks in men [32]. The present
data indicated that the SBP recovery ratios consistently
related positively to resting HR in both genders. This
indicates that a low resting HR will result in faster SBPR
and vice versa. No previous study to our knowledge has
associated resting HR to SBPR. The present result how-
ever was expected since changes in blood pressure are
usually mediated by the baroreflex mechanism via HR
changes [34]. The baroreflex mediated response of HR
to changes in arterial blood pressure indicates the capac-
ity of reflex cardiac autonomic modulation [35]. Fur-
thermore, low resting HR has been reported to be a par-
tial surrogate for good conditioning and regular exercise
[6] and reflects good health [1], whereas higher values
are related to higher cardiovascular mortality [36]. Si-
milarly, faster SBPR after exercise has been previously
related to higher physical activity and fitness level [12],
while a delayed (slower) SBPR is associated with in-
creased risk of cardiovascular diseases. The level of
physical activity has been previously associated with
SBP responses to exercise [37] and generally regarded as
a very important risk factor for cardiovascular diseases.
The rate at which SBP declines after exercise is sug-
gested to be a reflection of a person’s level of physical
activity and fitness; a more rapid decline indicates a
higher level of physical fitness, and a greater decrease in
SBP from peak exercise to the recovery may reflect good
aerobic capacity [12]. In the present study, a higher
physical activity level of subjects was associated with
faster SBPR and consistent with the previous studies.
The mechanisms behind the observed relationship be-
tween physical activity and SBPR are not very clear.
However, this may be connected with the effect of exer-
cise training in improving vascular endothelial functions
and vasodilatory capabilities, hence a decrease in sys-
temic vascular resistance [38,39]. Cigarette smoking has
been shown to increase blood pressure and HR, decrease
exercise tolerance and is associated with cardiovascular
diseases such as coronary heart disease, stroke, and pe-
ripheral vascular diseases [40]. However no study has
associated cigarette smoking with SBPR. In this study,
cigarette smoking indicated independent and positive
associations with delayed SBP recovery in both genders.
Smokers showed 0.10 higher SBPR2 than non-smokers
in both genders.
These results may be a reflection of poor response of
SBP to exercise in poorly conditioned smokers. The me-
chanism by which smoking slows down SBP recovery is
not well understood, but it is thought that smoking
through the activities of nicotine and carbon monoxide
contributes to the aggravation and acceleration of arterial
wall stiffness and inelasticity [18], thus increasing sys-
temic arterial resistance.
In order to determine the relationship between gender
and SBPR, we combined the data for men and women to
perform a multiple regression analysis adjusting for all

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the other variables. Our data showed that men showed
0.25 higher SBPR2 than women. This result indicates
that women demonstrated faster SBPR than men and
inconsistent with our previous study [9]. Previous stud-
ies [12,16] have suggested that SBP recovery will be
delayed with increased sympathetic activity and attenu-
ated vagal reactivation. It has also been reported that at
all ages women have been found to have reduced sym-
pathetic activity and enhanced parasympathetic activity
relative to men [41]. Epidemiological studies have also
demonstrated a gender difference in the incidence of car-
diovascular disease, with women, particularly younger
women, at much lower risk of developing cardiovascular
disease than their age matched men [5]. These facts sup-
port our present findings in which women indicated
faster SBPR than males. It is noteworthy that among all
the variables studied, age in men and physical activity in
women indicated the strongest associations with SBPR.
Previous studies [11,12] have demonstrated the impor-
tance and influence of age and physical activity on
SBPR but none to our knowledge has compared the
strength of associations of predictive variables with SBP
recovery. The present findings therefore may suggest
that age in men and physical activity status in females
should be given more importance when evaluating
changes in SBP recovery and during screening of asso-
ciated cardiovascular events. Further studies are how-
ever needed to strengthen these findings.
5. LIMITATIONS OF STUDY
Our study involved adults who performed ergometer
exercise tests at a sub maximal level (vigorous exercise
intensity). In addition, we evaluated systolic blood pres-
sure recovery during inactive exercise recovery mode.
Our study therefore may not apply to SBP recovery from
other exercise types and intensities; or to other cycling
exercise recovery modes. Further studies are therefore
recommended in these areas.
6. CONCLUSIONS
In summary, the present study indicated independent rela-
tionships between SBP recovery and variables known to
associate with cardiovascular abnormalities such as age,
BMI and waist circumference, resting HR, physical ac-
tivity, and cigarette smoking in at least one gender-
specific group of apparently healthy adults. These findings
strengthen the previously reported prognostic importance
of post-exercise SBP recovery in diagnosing cardiovascu-
lar abnormalities in healthy adults undergoing exercise
stress tests. Additionally, it will provide a better basis on
which to define and interpret the mechanisms behind
changes in post-exercise SBP responses in healthy adults
undergoing stress tests in future investigations.
7. ACKNOWLEDGEMENTS
I like to thank Mr. Victor Sylvester, Centre Manager, Mdm. Annie
cheng, Senior Deputy Principal, Staff and Physiotherapy Students of
Masterskill university college, Sabah, Malaysia for their Support and
Co operation to initiate and perform this Research work.
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