Association between Exercise-Induced Hypertension and Heart Rate Variability, Arterial Stiffness

Kang, Seol-Jung; Ko, Kwang-Jun; Ha, Gi-Chul; Seol-Jung Kang; Kwang-Jun Ko; Gi-Chul Ha

doi:10.15857/ksep.2025.00402

Exerc Sci > Volume 34(4); 2025 > Article

Kang, Ko, and Ha: Association between Exercise-Induced Hypertension and Heart Rate Variability, Arterial Stiffness

Original Article

Exerc Sci. 2025; 34(4): 478-485.

Published online: Nov 28, 2025

DOI: https://doi.org/10.15857/ksep.2025.00402

Association between Exercise-Induced Hypertension and Heart Rate Variability, Arterial Stiffness

Seol-Jung Kang PhD¹

, Kwang-Jun Ko PhD²

, Gi-Chul Ha PhD^2,

¹Department of Physical Education, Changwon National University, Changwon, Korea

²Department of Sports Medicine, National Fitness Center, Seoul, Korea

Corresponding author: Gi-Chul Ha Tel +82-10-4712-2674 Fax +82-2-413-5322 E-mail hagc@naver.com

*This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2023S1A5B5A17084785)

*The research was conducted after undergoing ethics review by the Research Ethics Committee of Changwon National University (No. 7001066-202309-HR-056).

Received Jun 25, 2025 Revised Aug 11, 2025 Accepted Sep 8, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

PURPOSE

Exercise-induced hypertension (EIH) affects future cardiovascular disease (CAD) events. We evaluated the association between EIH and heart rate variability (HRV), which reflects autonomic nervous system activity and arterial stiffness.

METHODS

The study participants were 202 adults aged 30–60 years (151 men and 51 women) who visited the National Fitness Center in South Korea, a health examination institution, from October 2023 to June 2024. During exercise testing, participants were classified into the EIH group (n=49) and the normal group (n=153) based on a systolic blood pressure (SBP) of ≥210 and ≥190 mmHg for men and women, respectively. HRV was analyzed for total power (TP), low-frequency (LF), and high-frequency (HF). Arterial stiffness was evaluated using brachial-ankle pulse wave velocity (ba-PWV). In this study, arteriosclerosis was defined as a ba-PWV≥1,400 m/s.

RESULTS

There were no significant differences in HRV indicators (TP, LF, HF, and LF/HF) between the groups; however, the EIH group showed a significantly higher ba-PWV than the normal group (p<.001). There was no significant difference in the correlation between peak SBP and HRV indicators. However, there was a significant correlation between the peak SBP and ba-PWV (R=0.152, p<.05). The relative risk of atherosclerosis, which was adjusted for confounding factors, was 3.13 times higher in the EIH group than in the normal group (95% confidence interval [CI], 1.52–6.65, p<.01).

CONCLUSIONS

EIH, which reflects CAD prognosis, is related to ba-PWV, an index of arterial stiffness.

Keywords: Exercise-induced hypertension, Heart rate variability, Arterial stiffness, Brachial-ankle pulse wave velocity

INTRODUCTION

Hypertension is a condition characterized by high arterial blood pressure and is a known risk factor that directly impacts the incidence and mortality of coronary artery disease (CAD) [1]. The diagnosis of hypertension is based on the resting blood pressure reading, which is determined by the hemodynamic laws of cardiac output and peripheral vascular resistance [2]. During exercise, systolic blood pressure (SBP) rises because cardiac output increases 4-5 folds due to sympathetic hyper-function and parasympathetic inhibition of the autonomic nervous system [3,4]. In contrast, diastolic blood pressure (DBP) during exercise typically either remains stable or decreases due to vasodilation and reduced peripheral vascular resistance. However, there are cases of excessive SBP responses during exercise testing, known as exercise-induced hypertension (EIH) [5,6].

EIH is defined by a normal resting SBP and DBP of 140/90 mmHg or less, but where SBP rise threshold 210 mmHg for men and 190 mmHg for women during exercise testing [7,8]. Multiple studies have reported an increased risk of future hypertensive morbidity and CAD in patients with an EIH response [9-11]. While the mechanism of EIH remains un-clear, it has been suggested that EIH may be caused by overactivity of the sympathetic nervous system, which can be seen as a dysfunction of the autonomic nervous system-a system that plays a crucial role in regulating blood pressure [12,13]. In clinical practice, heart rate variability (HRV) testing, which quantifies temporal variations in the cardiac cycle, has been effectively used to analyze autonomic nervous system activity [14]. The low-frequency (LF) region of the HRV indicator is regulated by both the sympathetic and parasympathetic nerves, though it is typically used as a sympathetic indicator, while the high-frequency (HF) region reflects parasympathetic activity. The LF/HF ratio serves as an indicator of the balance between sympathetic and parasympathetic nervous systems [15]. Reduced HRV has been reported in previous studies to affect the development of hypertension [16,17].

It has also been suggested that the development of EIH is related to left ventricular hypertrophy and vascular endothelial cell hypofunction, which can be attributed to arterial stiffness [18-21]. Arterial stiffness reflects structural and functional changes in blood vessels, and like HRV, can be assessed noninvasively using pulse wave velocity (PWV) in clinical practice [22,23]. PWV reflects atherosclerotic vascular damage and is known to be associated with SBP [24,25]. Furthermore, increased arterial stiffness in hypertensive patients has been strongly associated with the occurrence and prognosis of CAD events [26]. Arterial stiffness is also reported to impact the EIH response [27,28].

However, studies confirming the association between HRV and arterial stiffness, which can determine autonomic nervous system dysfunction and vascular function in EIH that increases the risk of future CAD events, are extremely rare. Therefore, the purpose of this study was to compare and analyze HRV and arteria stiffness between the EIH group and the normal control group during exercise testing in healthy adults with resting normotension, and to determine the association between each of these measured variables.

METHODS

1. Participants

This study was conducted on 202 adults (151 male, 51 female) aged between 30 and 60 years of age who underwent health examinations including exercise tests, HRV tests, and ba-PWV tests at the National Fitness Center in Seoul from January to December 2023.

The purpose and content of the study were sufficiently explained to the subjects and consent forms for participation in the experiment were obtained before the experiment was conducted. In this study, the diagnosis criteria for EIH were set as an increase of 210 mmHg or more in men and 190 mmHg or more in women based on SBP during the exercise test [7,8]. Among the study subjects, those with resting SBP and DBP ≥140/90 mmHg, those with an ankle-brachial index of 0.9 or lower, which does not accurately reflect arterial stiffness, those with CVD, chronic obstructive pulmonary disease, those taking antihypertensive medication, and those with diseases affecting the autonomic nervous system were excluded. The number of subjects in this study was calculated using the G*Power 3.1 program, which is the required sample size of 190 when the significance level is 0.05, the effect size is 0.3, and the power is 0.8 in a two-sided correlation test. The final sample size was determined to be 202 participants (EIH group 49 and normal group 153). The study was approved by the ethics review committee (Institutional Review Board of 000: 7001066-202309-HR-056).

2. Health survey

All subjects were given a self-administered questionnaire to survey present and past medical history, drug use history, drinking, smoking, and exercise. The current drinking times over week (unit: drinking cup) were surveyed. For smoking, subjects were classified current smoker and non-smokers. Those who had not smoker for at least 6 months were classified as non-smoker. Subjects who practiced physical activity or exercise at least 150 minutes per week were indicated.

3. Physical measurement examination

Subject's Height and weight were measured using an automatic anthtropometric instrument (SH-9600A; o2run, Seoul, Korea). Body mass index (BMI) was calculated as body weight (kg)/height (m)². For blood pressure testing, subjects were induced to rest for at least 10 minutes, and then SBP and DBP were measured at the left brachial artery at the same height of the heart by means of automatic blood pressure measuring de-vice (FT500R; Jawon Medical, Seoul, Korea). If the blood pressure was not in the normal range, the subject was induced to rest for 10 minutes, and then the blood pressure was measured again. The Blood test was implemented by means an automatic biochemical analyzer performed (Hitachi 7600-110, Hitachi Co., Tokyo, Japan) after gastric emptying for at least 10 hours. Measurement items included total cholesterol (T-Chol), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (FBG).

4. Exercise test

The exercise test was conducted by treadmill (Medtrack ST 55; Quinton, Boston, USA), and the modified Bruce protocol. The following items were measured at every 15 seconds by means of a breathing gas analyzer (Q4500; Quinton, Boston, USA), and an automatic heart rate monitor. SBP and DBP were measured at each stage of the exercise test using an automatic blood pressure monitor. For the criteria of determination in the exercise test, because there was little change in the oxygen intake of the subject even if there was a symptom such as difficult breathing and fasting while exercise intensity increased, the exercise was considered to have been completed when the ratings of perceived exertion was at least 15, the heart rate reached 90% of the target heat rate (220-age), and the respiratory exchange ratio was at least 1.15.

5. HRV-test

HRV test was measured using an autonomic nervous system tester (DPA; MEDIDIAN, Seoul, Korea). The subjects rested for at least 10 minutes before measurement, and the electrodes were attached to both wrists and left ankles of the subjects in a sitting position, and the measurement was made for 5 minutes. There are time domain analysis and frequency domain analysis for HRV analysis. In this study, the analysis item in the time domain was the total power, which represents the entire activity of the autonomic nervous system. In the frequency domain, the LF region (0.05-0.15 Hz) reflecting the sympathetic nerve activity of the heart, the HF region (0.15-0.5 Hz) reflecting the parasympathetic nerve activity of the heart, and LF/HF ratio indicating the balance of the autonomic nervous system were used.

6. brachial-ankle pulse wave velocity (ba-PWV) test

The ba-PWV test was measured using an automatic waveform analyzer (HBP-8000; OMRON, Seoul, Korea) after the subject rested in the supine position for at least 10 minutes. The time interval (△ T) required to determine ba-PWV was obtained from the pulse waves recorded from the right arm and both legs, and the distance (L) between the measurement points was automatically calculated by the waveform analyzer using the subject's height. The ba-PWV of each side was obtained by dividing the time interval (△ T) by the distance (L) between the measurement points. In this study, the average value of the ba-PWV values on both sides was used as ba-PWV. In addition, the risk of arteriosclerosis according to ba-PWV was set to ba-PWV ≥1,400 m/s, which is the reference value for predicting the risk of CAD, based on a previous study [29].

7. Statistical analysis

For continuous variables of each measurement items, mean (M) and standard deviation (SD) are indicated. Categorical variables are presented with frequency and percentage. Independent t-test was performed to compare each measurement value between the EIH and normal groups.

The correlation between the peak SBP and HRV index and ba-PWV of the exercise test was analyzed using Pearson's correlation coefficient. In addition, logistic regression analysis was used to calculate the odds ratio to confirm the cross-sectional correlation between the EIH group and the normal group with arteriosclerosis (ba-PWV ≥1,400 m/sec). Model 1 was not adjusted, and model 2 adjusted for age, sex, BMI, exercise level, drinking history, and smoking history. Model 3 additionally adjusted for SBP, DBP, T-Chol, TG, LDL-C, HDL-C, and FBG in model 2. Statistical analysis was performed using the SPSS version 23.0 (SPSS Inc., Chicago, IL, USA) statistical program. The statistical significance level (α) was set at p <.05.

RESULTS

1. Comparison of general characteristics between EIH group and normal group

In this study, the EIH group 49 individuals (men=36, women=13) and normal group 153 individuals (men=115, women=38). The average ages of men and women were 48.3±7.3 and 46.1±8.07 years, respectively, and there were no significant differences in height, weight, BMI, or body fat percentage (% fat) between EIH group and normal group. There was a significant difference between the EIH group and normal group in HDL-C (p <.05). On the other, there was no significant difference in T-Chol, TG, LDL-C, peak oxygen uptake (VO₂ max) (Table 1).

Table 1.

Characteristics of the study subjects

Variables	EIH group (n=49)	Normal group (n=153)	p-value
Gender (Men/Women)	36/13	115/38
Age (yr)	48.37±7.31	46.12±8.07	.084
Height (cm)	168.98±4.56	169.85±5.12	.290
Weight (kg)	72.63±8.07	73.19±9.30	.703
BMI (kg/m²)	25.44±2.73	25.39±2.76	.911
% Fat	25.27±4.68	24.98±3.99	.673
Exercise status (%)	47 (95.9)	142 (92.8)	.529
Smoking status (%)	8 (16.3)	25 (16.3)	.998
Drinking status (%)	47 (95.9)	143 (93.5)	.443
T-Chol (mg/dL)	195.24±30.89	189.31±30.43	.238
TG (mg/dL)	125.86±57.10	129.16±55.57	.719
LDL-C (mg/dL)	106.14±28.39	109.61±27.02	.440
HDL-C (mg/dL)	61.41±14.72	56.21±12.95	<.019
FBG (mg/dL)	93.84±12.40	91.59±12.98	.287
VO_₂ max	37.02±6.53	35.81±5.49	.200

Data shown as Mean±SD or n (%).

Exercise status; ≥30 min/day on ≥3 day/week, Smoking status; ≥1 cigarettes daily, Drinking status; ≥ once/month.

EIH, exercise-induced hypertension; BMI, body mass index; T-Chol, total cholesterol; TG, triglycerides; LDL-C, low density lipoprotein cholesterol; HDL-C, high density lipoprotein cholesterol; FBG, fasting blood glucose.

Tested by t-test or chi-square test.

2. Comparison of blood pressure between EIH and normal groups

The resting SBP of the EIH group was 128.71±10.35 mmHg, the DBP was 81.45±6.46 mmHg, and the resting SBP of the normal group was 124.59±11.38 mmHg, the DBP was 78.08±7.56 mmHg, showing significant differences, respectively (p <.05, p <.01). In the exercise testing, the peak SBP of the EIH group was 222.98±10.86 mmHg, the DBP was 89.57±9.32 mmHg, and the peak SBP of the normal group was 182.37±22.520 mmHg, the DBP was 80.86±9.82 mmHg, showing significant differences, respectively (p <.001, p <.001) (Table 2).

Table 2.

Comparison of blood pressure between EIH and normal groups

Variables	EIH group (n=49)	Normal group (n=153)	p-value
SBP (mmHg)	128.71±1.35	124.59±11.38	<.025
DBP (mmHg)	81.45±6.46	78.08±7.56	<.006
peak SBP (mmHg)	222.98±1.86	182.37±22.52	<.001
peak DBP (mmHg)	89.57±9.32	8.76±9.82	<.001

Data shown as Mean±SD.

EIH, exercise-induced hypertension; SBP, systolic blood pressure; DBP, diastolic blood pressure.

3. Comparison of HRV indices between EIH and normal groups

The EIH group showed higher total power, LF, and HF than the normal group, but there was no significant difference. The LF/HF ratio was lower in the EIH group than in the normal group, but there was no significant difference (Table 3).

Table 3.

Comparison of HRV indices between EIH and normal groups

Variables	EIH group (n=49)	Normal group (n=153)	p-value
Total power	3,121.61±4,237.01	2,870.60±3,973.46	.705
LF	1,051.81±2,093.69	992.73±1,794.27	.848
HF	708.79±1,337.66	671.94±1,371.85	.869
LF/HF ratio	1.98±1.50	2.08±1.71	.711

Data shown as Mean±SD.

EIH, exercise-induced hypertension; LF, low frequency; HF, high frequency. Tested by t-test.

4. Comparison of ba-PWV between EIH and normal groups

The ba-PWV in the EIH group was significantly higher than that in the normal group (p <.001) (Table 4).

Table 4.

Comparison of ba-PWV between EIH and normal groups

Variables	EIH group (n=49)	Normal group (n=153)	p-value
ba-PWV	1,435.67±206.71	1,272.28±199.08	<.001

Data shown as Mean±SD.

Tested by t-test.

5. Correlation between peak SBP and HRV indices

Peak SBP was positively correlated with total power (r=-0.001, p = .984), LF (r=-0.017, p =.812). but no significant difference was observed. There was also a positive correlation between HF (r=0.008, p =.912) and LF/HF ration (r=0.013, p =.860), but no significant difference was observed (Fig. 1A, B, C, D).

Fig. 1.

Correlation of Peak SBP and HRV index (TP, LF, HF, LF/HF). TP, total power; LF, low frequency; HF, high frequency.

6. Correlation between peak SBP and ba-PWV

Peak SBP was positively correlated with ba-PWV (r=0.152, p =.033) (Fig. 2).

Fig. 2.

Correlation of peak SBP and ba-PWV. ba-PWV, brachial-ankle pulse wave velocity.

7. Odds ratio of having the atherosclerosis according to EIH

According to the logistic regression analysis results, in model 1, the risk of atherosclerosis was 2.9 folder higher in the EIH group than in the normal group (OR, 2.90; 95% CI, 1.59-5.62, p <.01). In model 2, the risk of atherosclerosis was 2.73 folder higher in the EIH group than in the normal group (OR, 2.73; 95% CI, 1.39-5.33, p <.01). In addition, in model 3 including all confounding variables, the risk of arteriosclerosis was found to be 3.13 folder higher in the EIH group in the normal group (OR, 3.13; 95% CI, 1.49-6.55, p <.01) (Table 5).

Table 5.

Odds ratio of having the arteriosclerosis according to EIH

Variables	Model 1		Model 2		Model 3
Variables	OR	(95% CI)	OR	(95% CI)	OR	(95% CI)
Normal group	1 (reference)		1 (reference)		1 (reference)
EIH group	2.90	1.59-5.62	2.73	1.39-5.33	3.13	1.49-6.55
p for trend	<.002		<.003		<.002

EIH, exercise-induced hypertension; OR, odds ratio.

Model 1: unadjusted.

Model 2: adjusted for sex, age, body mass index, exercise, smoking, drinking.

Model 3: adjusted for sex, age, body mass index, exercise, smoking, drinking, systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, low density lipoprotein cholesterol, high density lipoprotein cholesterol, fasting blood glucose.

DISCUSSION

This study investigates the association between EIH, HRV, and arterial stiffness in healthy adult men and women with normal resting blood pressure. In this study, there was no correlation between peak SBP and HRV indicators during exercise testing, but there was a positive correlation with ba-PWV. We also found that the EIH group had a 3.13 folds higher relative risk of developing atherosclerosis compared to the normal group.

Exercise causes physiological stress on the cardiovascular system, and it is a normal response for SBP to rise due to cardiac output and sympathetic nerve activation [9-11]. However, EIH - an excessive increase in blood pressure during exercise - is known to increase the morbidity of future hypertension and CAD. It has been suggested that arterial stiffness, which causes autonomic nervous system dysfunction and structural changes in blood vessels due to excessive sympathetic nervous system activation, is a contributing factor [30,31].

HRV is a measure of temporal variations in the cardiac cycle and provides useful information about autonomic nervous system function within the cardiovascular system. In HRV analysis, total power reflects overall autonomic nervous system activity, HF reflects parasympathetic nervous system activity, and LF reflects sympathetic nervous system activity [32]. Previous studies have shown that people with hypertension have a lower HRV, and the lower the HRV, the higher the risk of developing hypertension in the future [33]. The results of this study showed no significant differences in any HRV indicator between the EIH and normal groups. There was also a negative correlation between peak SBP, TP, and LF, and a positive correlation with HF and LF/HF, but no significant difference was identified. In contrast, Eryonucu et al. [34] found that the absolute value (delta SBP) difference between SBP measured at each stage of the Bruce protocol and the resting SBP during exercise testing was greater than 40 mmHg, indicating that those with hypertensive responses had higher rates of LF and LF/HF compared to the normal group. Gaudreault et al. [12] found a negative correlation between peak SBP during exercise testing and the total HRV indicator measured by 24-hour Holter in the metabolic syndrome group with normal resting blood pressure. Unlike previous studies, this study did not identify differences in HRV measure variables between the two groups or any significant association between peak SBP and HRV indicators. This may be due to the small number of subjects in the EIH group and the fact that HRV is subject to significant interindividual variations due to testing conditions such as measurement time, respiratory rate, diurnal variation, and psychological stress. To overcome this, it is believed that further studies with larger subject numbers and controlled examination circumstances that affect HRV are needed.

PWV measures the speed at which pulse waves generated by blood pressure propagate through the arteries and is a recognized clinical indicator of arterial stiffness [22,23]. Previous studies have shown that the risk of future CAD events is higher at high PWV compared to low PWV, as reduced vascular elasticity accelerates PWV [35,36]. PWV levels are known to increase with aging, hypertension, and other risk factors for atherosclerotic CAD [37,38]. The results of this study demonstrated that the EIH group had a higher ba-PWV than the normal group, and peak SBP was positively correlated with PWV. Similar to this study, Thanassouli et al. [39] found that higher SBP was associated with higher PWV in the second stage of the Bruce protocol during exercise testing in Framingham Offspring cohort participants. Research from the Framingham Heart Study participants by Nayor et al. [40] also found that peak SBP during exercise testing was associated with PWV. Haarala et al. [41] reported that in adult men and women, high PWV was associated with SBP at each stage and peak SBP during exercise testing. Furthermore, structural changes in the left ventricle have been cited as important in explaining the pathophysiologic pathogenesis of EIH [5,42]. In this regard, it can be concluded that EIH is affected by arterial stiffness, which reflects negative vascular structural changes, and this study supports this conclusion.

While the threshold for PWV-induced arterial stiffness has not been clearly established, a study by Yamashina et al. [29] confirmed that a ba-PWV greater than 1,400 cm/s was associated with an increased risk of developing atherosclerosis, the leading cause of CAD. This study also performed a logistic regression analysis using ba-PWV ≥1,400 cm/s as an indicator of atherosclerosis. The results showed that the relative risk of developing atherosclerosis was 3.13 folds higher in the EIH compared to the normal group, after adjusting for confounding variables such as age, gender, BMI, exercise, smoking, drinking, SBP, DBP, T-Chol, TG, HDL-C, LDL-C, and FBG. This supports multiple studies [43,44] that have shown an increased risk of atherosclerotic CAD events in those with an EIH response. This suggests that EIH is clinically important in healthy adults with no apparent risk of developing CAD.

This limitation of this study is that it is difficult to generalize that the association between EIH and PWV, arterial stiffness in adults who visited a local health examination center. Also, although the number of participants in the EIH group was relatively small compared to the normal group, the results of the analysis may be less significant. Despite this limitation, we believe this study is significant in that it found that EIH was not associated with HRV (which assesses autonomic nervous system activity) but was significantly associated with ba-PWV, a marker of arterial stiffness.

CONCLUSION

This study examined the association between EIH and HRV, ba-PWV in adults with normal resting blood pressure. The results of this study revealed no correlation between peak SBP and HRV indices. However, a positive correlation was found between peak SBP and ba-PWV. Furthermore, individuals with EIH group had a higher relative risk of atherosclerosis compared to those with normal group. Therefore, it is recommended that a proactive strategy be developed to prevent CAD events in individuals exhibiting an EIH response, even when their resting blood pressure is normal.

Notes

CONFLICT OF INTEREST

All authors declare that they have no conflicts of interest with the contents of this study.

AUTHOR CONTRIBUTIONS

Conceptualization: SJ Kang; Data curation: KJ Ko, GC Ha; Formal analysis: GC Ha; Funding acquisition: GC Ha; Methodology: SJ Kang; Project administration: SJ Kang, KJ Ko, GC Ha; Visualization: KJ Ko, GC Ha; Writing - original draft: SJ Kang; Writing - review & editing: SJ Kang.

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