Methodological challenges in integrating exercise blood pressure and cardiorespiratory fitness for cardiovascular risk assessment: insights from the EXERTION study

This commentary refers to ‘Exercise blood pressure relative to fitness and cardiovascular outcomes: the EXERTION study’, by M. G. Schultz et al., https://doi.org/10.1093/eurheartj/ehaf1082 and the discussion piece ‘Exercise blood pressure relative to fitness: pragmatic clinical potential’, by M. G. Schultz et al., https://doi.org/10.1093/eurheartj/ehag444. We have read with great interest the article by Schultz et al.1 which proposes a novel composite index integrating exercise blood pressure and physical fitness. While this index delivers meaningful clinical insights, several key facets would benefit from in-depth discussion. First, as a multicentre study, it lacked consistency in blood pressure measurement techniques across centres. Wohlfahrt et al.2 demonstrated that different methods could yield a mean systolic blood pressure difference of ∼10 mmHg, potentially distorting hypertension prevalence estimates in the general population. Insufficient standardization and reporting of exercise blood pressure measurements may attenuate the observed associations and limit the generalizability of the proposed thresholds. Future studies should standardize and explicitly report measurement protocols to improve the comparability and reliability of results.