Waist-to-height ratio (WHtR) is the dominant anthropometric predictor of workload-indexed exercise systolic blood pressure, statistically accounting for 80–90% of the insulin-resistance signal, while ESC and AHA definitions classify approximately one in seven patients discordantly.
Key Findings
Results
Waist-to-height ratio was the dominant predictor of workload-indexed exercise systolic blood pressure in multivariable regression.
β = +8.96 mmHg per W·kg-1 per 1-SD increase in WHtR, p < 0.001
The model explained R² = 0.61 of variance in the primary endpoint (peak SBP ÷ W·kg-1)
WHtR remained statistically significant across all eleven workload-indexing methods tested, including the SBP/MET slope and after VO2peak adjustment
WHtR also predicted peak SBP itself (p < 0.001)
The association was independent of sex (sex × WHtR interaction p = 0.31)
Results
WHtR statistically mediated 80–90% of the effect of both insulin-resistance surrogates on workload-indexed exercise SBP.
The two insulin-resistance surrogates tested were HOMA-IR and the triglyceride/HDL ratio
Formal statistical mediation analysis was conducted using the Sobel test (Sobel p < 0.001 for both surrogates)
WHtR accounted for 80–90% of the effect of both surrogates, indicating that central adiposity is the proximal pathway rather than the blood-based metabolic markers themselves
Results
The association between WHtR and workload-indexed exercise SBP was modified by age but not by sex.
Age × WHtR interaction was statistically significant (p = 0.014)
Sex × WHtR interaction was not significant (p = 0.31)
The study population consisted of 324 working-age adults from a Czech preventive-cardiology cohort
Results
ESC and AHA definitions of exaggerated exercise SBP response classified approximately one in seven patients discordantly.
47 of 324 patients (14.5%) were classified discordantly between ESC and AHA definitions
Agreement between the two guideline definitions was κ = 0.67
This level of discordance motivates harmonisation of guideline thresholds according to the authors
Results
A workload-adjusted definition using SBP/MET slope classified more patients as having an exaggerated response and showed no age dependence.
The workload-adjusted definition used a threshold of SBP/MET slope > 10 mmHg·MET-1
This definition classified 24.4% of participants as having an exaggerated exercise SBP response
It reclassified one in five patients compared to the ESC definition
Unlike the ESC definition, the workload-adjusted definition showed no age dependence, suggesting it may be less susceptible to age-related misclassification
Methods
The study used a cross-sectional design with bicycle cardiopulmonary exercise testing in 324 working-age adults.
All participants completed a valid bicycle cardiopulmonary exercise test (CPET) at a Czech preventive-cardiology centre
The pre-specified primary endpoint was peak SBP indexed by relative workload (peak SBP ÷ W·kg-1)
Confirmatory multivariable linear regression was the primary statistical method
Binary outcomes were analysed under parallel ESC, AHA, and workload-adjusted definitions
Cross-sectional design limits causal inference
What This Means
This research suggests that a simple body measurement — waist circumference divided by height (waist-to-height ratio, or WHtR) — is the single strongest predictor of how much a person's blood pressure rises during exercise relative to how hard they are working. The study followed 324 working-age adults who completed a bicycle fitness test at a preventive cardiology centre in the Czech Republic. Rather than just measuring peak blood pressure during exercise, the researchers adjusted blood pressure values by the workload achieved, which is more meaningful because fitter people naturally reach higher workloads and higher absolute blood pressures. WHtR outperformed blood tests for insulin resistance (such as HOMA-IR and the triglyceride/HDL ratio), and the statistical analysis showed that WHtR explained 80–90% of the link between those blood markers and exercise blood pressure — meaning the connection between poor sugar and fat metabolism and exercise blood pressure appears to work largely through belly fat rather than through the blood markers themselves.
The study also found that two major medical guideline bodies — the European Society of Cardiology (ESC) and the American Heart Association (AHA) — disagree about whether a patient's exercise blood pressure response is abnormal in about 1 in 7 cases. An alternative approach that adjusts blood pressure rise by exercise intensity (MET level) flagged more people as having an abnormal response and was not influenced by age the way the guideline-based definitions were, raising questions about which approach best identifies people truly at risk.
This research suggests that measuring waist circumference and height — tools that cost nothing and require no laboratory — could be a practical first step to identify people likely to have an exaggerated blood pressure response to exercise, which is known to predict future hypertension and cardiovascular events. The findings also highlight the need for cardiologists and guideline bodies to agree on a standard definition of what counts as an abnormally high exercise blood pressure, particularly one that accounts for how hard a person is actually working during the test.
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Puskasova K, Jiravska-Godula B, Samiec J, Jiravsky O, Szotkowska V, Kantor M, et al.. (2026). Waist-to-height ratio is the proximal correlate of workload-indexed exercise systolic blood pressure: a Czech preventive-cardiology cohort study.. Blood pressure. https://doi.org/10.1080/08037051.2026.2701515