Journal of Human Hypertension (2017), 1–8

© 2017 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0950-9240/17
www.nature.com/jhh

REVIEW
A systematic review and meta-analysis of exercise and exercise
hypertension in patients with aortic coarctation
HJA Foulds1, NB Giacomantonio2,3, SSD Bredin4,5 and DER Warburton4,6,7

Exercise hypertension is a common occurrence among individuals with aortic coarctation. Although exercise is known to be
beneficial among the general population, the risks and benefits of exercise among those with aortic coarctation are less clear. This
systematic review evaluates the benefits and risks of exercise for persons with aortic coarctation. Electronic databases were
systematically searched (that is, MEDLINE and EMBASE) and key reviews cross-referenced to identify articles for inclusion. Original
research articles reporting exercise among individuals with aortic coarctation were included. From 2608 individual citations, 68
eligible articles were identified. Aerobic exercise stress tests were found to be useful for determining exercise hypertension
experiences post-surgical repair (N = 5), and other long-term secondary findings (N = 3). Experiences of exercise hypertension were
associated with abnormal cardiac and/or aortic geometry and cardiac function (N = 7). Exercise capacity was generally found to be
similar to non-aortic coarctation controls post surgery (N = 6). Exercise hypertension was experienced by 27% of participants,
including 10% of adults and 43% of children/youth. Individuals who experience exercise hypertension experience greater increases
in systolic blood pressure with exercise. No investigations identified evaluated forms of exercise other than aerobic stress tests and
no exercise training programs have been conducted to date. Exercise stress tests can be valuable in this population for determining
exercise hypertension, especially in the year post-surgical repair. Additional research is urgently needed to accurately assess the
benefits and risks of exercise and exercise hypertension, and applicability of exercise restrictions for this population.

Journal of Human Hypertension advance online publication, 3 August 2017; doi:10.1038/jhh.2017.55

INTRODUCTION aortic coarctation generally demonstrate reduced exercise capa-

Aortic coarctation is a common congenital heart disease,
accounting for 4–7% of congenital cardiovascular disease.1,2 This
condition develops from narrowing of the aortic isthmus or
underdevelopment of the aortic arch prenatally.3 Aortic coarcta-
tion results in histological abnormalities, increased risks of
aneurisms, increased cardiovascular disease and blood
pressures.3 Surgical treatment of aortic coarctation generally
occurs early in life.1
Exercise and physical activity are known to reduce morbidity
and mortality among the general population.4,5 Among many
other cardiac conditions, exercise benefits have also been
established.6,7 However, exercise hypertension is known to occur
among individuals with aortic coarctation.2,8 Among the general
population, exercise systolic hypertension is associated with
higher incidence of myocardial infarction, stroke, cardiovascular
and all-cause mortality.9–11 Specific to aortic coarctation, the
associations and risks of exercise hypertension have yet to be
evaluated. Current guidelines for adults define exercise hyperten-
sion as blood pressures above 250 mm Hg systolic or 115 mm Hg
diastolic.12 Guidelines for children and adolescents are not
available, although recent normative data have been prepared.13
Individuals with aortic coarctation may experience reduced
aerobic capacity, even after surgical repair.3 Further, adults with
city, due to poor physical conditioning.1,14 Challenges in balancing
the benefits of exercise with the risks and complications may exist
for this population.
Among individuals with aortic coarctation, benefits and risks of
exercise are not currently well understood and systematic reviews
evaluating exercise for this population are lacking. This systematic
review critically evaluates current literature, including all study
designs, to determine the evidence and potential benefits and
risks of exercise interventions and assessments, and physical
activity surveys for individuals with aortic coarctation.
MATERIALS AND METHODS
Criteria for considering studies for this review
A rigorous, evidence-based and systematic approach was used to
critically examine the evidence on exercise for individuals with
aortic coarctation (Supplementary Table S2). Included examina-
tions evaluated exercise among individuals with aortic coarctation,
including all forms of exercise: aerobic, resistance, flexibility and
stretching training. Included investigations were published peer-
reviewed English language journals, including any study design
and year. No follow-up was required and any main outcome
measures were acceptable, if exercise or physical activity data

1
College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 2Division of Cardiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia,
Canada; 3Department of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada; 4Physical Activity Promotion and Chronic Disease Prevention Unit, Vancouver,
British Columbia, Canada; 5Systematic Reviews Unit, University of British Columbia, Vancouver, British Columbia, Canada; 6Cardiovascular Physiology and Rehabilitation
Laboratory, University of British Columbia, Vancouver, British Columbia, Canada and 7Experimental Medicine Program, Department of Medicine, Faculty of Medicine, University of
British Columbia, Vancouver, British Columbia, Canada. Correspondence: Dr HJA Foulds, College of Kinesiology, University of Saskatchewan, 87 Campus Drive, Saskatoon,
Saskatchewan, Canada S7N 5B2.
E-mail: heather.foulds@usask.ca
Received 20 October 2016; revised 11 May 2017; accepted 14 June 2017
 Aortic coarctation and physical activity
HJA Foulds et al
2
were available. Investigations not reporting exercise specifically
among participants with aortic coarctation were excluded.
The search strategy was created and conducted, and results
were compiled to develop evidence-based exercise recommenda-
tions aortic coarctation.
Search strategy
Literature searches were conducted in the following electronic
bibliographical databases:
● MEDLINE (1948-July Week 3 2016, OVID Interface);
● EMBASE (1980-July Week 3 2016, OVID Interface);
● Cochrane Library (1900-July Week 3 2016, OVID Interface);
Electronic search strategies were created and conducted by
researchers experienced in systematic reviews using broad
Medical Subject Headings.
Screening
Duplicate citations were removed and two independent reviewers
evaluated citation titles and abstracts, without blinding of authors
or journals. Key studies and reviews were cross-referenced. Full
text versions of all citations appearing relevant were screened by
two independent reviewers. Reasons for exclusion were recorded.
Any article including exercise, either in a single session or a
training program, reporting results of individuals with aortic
coarctation was included. A common template was used for data
extraction of population, coarctation sample sizes, sex, number of
adults and children/youth, age range, mean and s.d., resting
hypertension, cardiac abnormalities, surgical treatments, defini-
tions of exercise hypertension, physical activity levels, details of
exercise stress tests, maximal aerobic capacity, adverse events,
number of exercise stress tests, duration of exercise, exercise
hypertension experiences, maximal heart rate, details of exercise
training programs, conclusions regarding exercise and key
exercise findings. In the case of disagreement (1%), a third
reviewer was used to achieve a full consensus.
percentage of participants experiencing events. Comparisons of
proportions and means were performed using meta-analysis
comparison of means (MedCalc Version 12.7.0.0, Ostend, Belgium).
RESULTS
A total 2608 citations were examined as identified in the electronic
database searches (Figure 1). A final 68 unique citations were
included following title, abstract and full text screening and cross-
referencing (Supplementary Table S1), including 2544 individuals,
both adults and children/youth, although only single session
aerobic exercise were identified. Children/youth were examined in
36 articles and adults 35, with 9 articles including pooled data of
children/youth (N = 3) and adults (N = 6) combined. Included
articles ranged from grade A to C and levels 1–4. The quality of
articles was generally high, averaging 10.6 (3–13) out of 15.
Few adverse events were reported beyond exercise hyperten-
sion. Across 15 articles specifically reporting adverse events other
than exercise hypertension, 8 articles reported no adverse events
(Supplementary Table S1). Experiences of exercise hypertension
could only be determined for aerobic exercise stress tests, as no
other forms of exercise were examined. Table 1 outlines adverse
event rates, where children/youth experienced greater adverse
event rates across all categories and measures (P o0.001). Adverse
events of exercise were reported to be lower among those who
underwent surgical repair at an early age (Grade 3A, 2 articles,
n = 23).

Level of evidence
Objective, standardized, pre-determined criteria were used to
determine the level and grade of evidence and quality of
investigations, as evaluated in previous systematic reviews.7,15,16
Levels of evidence were scored 1 through 4 reflecting study
design.15 Grades A through C were assessed for the strength of
findings.15 The quality of investigations was assessed using a
Downs and Black scoring system,16 as previously modified for
exercise reviews,7 assigning each article a score out of 15. Two
independent reviewers evaluated the level and grade of evidence
and quality of investigations with discussion to achieve consensus.
An overall grade and level of evidence were assigned to
recommendations reflecting the articles compiled in developing
the recommendation.

Analysis
Children/youth (0–17 years) and adults were analyzed separately
whenever possible. When data from children/youth and adults
could not be separated, the article was classified as either
children/youth (children/youth and 20–24 years) or adults (13–17
years and adults), or when pooled samples ranged beyond 13–24
years, according to the mean age of participants. Analyses were
performed including and excluding articles where children/youth
and adults were pooled. Adverse event rates were determined
overall, for exercise hypertension specifically, and according to
absolute and relative test termination criteria according to
American College of Sports Medicine guidelines.17 Exercise
hypertension was evaluated according to standard
definitions12,13 and as reported in articles. Calculated rates Figure 1. Results of the literature search for aortic coarctation and
included exercise sessions and minutes per event and the exercise.

Journal of Human Hypertension (2017), 1 – 8 © 2017 Macmillan Publishers Limited, part of Springer Nature.
 Aortic coarctation and physical activity
HJA Foulds et al
3
Table 1. Exercise adverse events in patients with aortic coarctation

Sample Adverse events Exercise hypertension Adverse event rates excluding Adverse event rates including
events exercise hypertension exercise hypertension

Adults only N = 155 N = 233 2.6% Participants 12.4% Participants

155 Sessions 268 Sessions 1 Per 39 aerobic stress tests 1 Per 9 aerobic stress tests
1574 Min 2796 Min 1 Per 394 min 1 Per 96 min
2 Exertional hypotension 25 Exercise
1 Dyspnea hypertension
1 Muscle weakness
Adults pooled N = 170 N = 233 2.4% Participants 11.7% Participants
170 Sessions 283 Sessions 1 Per 42 aerobic stress tests 1 Per 10 aerobic stress tests
1724 Min 2946 Min 1 Per 431 min 1 Per 102 min
2 Exertional hypotension 25 Exercise
1 Dyspnea hypertension
1 Muscle weakness
Children only N = 177 N = 381 5.1% Participants 29.7% Participants
123 Sessions 385 Sessions 1 Per 14 aerobic stress tests 1 Per 3 aerobic stress tests
1209 Min 4053 Min 1 Per 134 min 1 Per 32 min
8 Fatigue 118 Exercise
1 Monomorphic ventricular hypertension
tachycardia
Children pooled N = 263 N = 381 4.2% Participants 30.2% Participants
221 Sessions 385 Sessions 1 Per 20 aerobic stress tests 1 Per 3 aerobic stress tests
2300 Min 4053 Min 1 Per 209 min 1 Per 31 min
8 Fatigue 118 Exercise
1 Monomorphic ventricular hypertension
tachycardia
1 Dyspnea
1 Leg fatigue
Overall N = 433 N = 629 3.2% Participants 22.9% Participants
391 Sessions 668 Sessions 1 Per 28 aerobic stress tests 1 Per 4 aerobic stress tests
4025 Min 6999 Min 1 Per 287 min 1 Per 44 min
2 Exertional hypotension 143 Exercise
1 dyspnea hypertension
1 Muscle weakness

Children/youth exercise hypertension experiences were identi-
fied among 28 of 36 articles, including 735 individuals and 267
exercise hypertension experiences across 842 exercise sessions or
an estimated 8918 min of exercise (Figure 2). Exercise hyperten-
sion rates were similar (P40.05) when including or excluding
samples with adults pooled. Higher rates of exercise hypertension
were identified based on standard definitions compared with
reporting in articles: 43.2% (children/youth only and pooled) vs
33.0% (children/youth only, P = 0.005) or 34.4% (pooled, P = 0.01),
3 sessions/event (standard definition children/youth only and
pooled) vs 3 sessions/event (children/youth only, P = 0.004;
pooled, P = 0.01) and 27 min/event (children/youth only and
pooled) vs 35 min/event (children/youth only, P = 0.02).
Definitions of exercise hypertension varied across articles, from
4190 to 4300 mm Hg.18,19 Among 35 articles evaluating among
adults, exercise hypertension could be determined on 29 articles
(Figure 3). This includes 1191 individuals and 302 exercise
hypertension experiences across 1201 exercise sessions or an
estimated 13 049 min of exercise. Rates of exercise hypertension
among adults with coarctation were similar (P40.05) when
including or excluding samples pooled with children/youth. Lower
rates of exercise hypertension were identified based on standard
definitions compared with reporting in articles: 10.7% (adults only
and pooled) vs 25.0% (adults only, P o0.001) or 25.4% (pooled,
P o0.001), 11 sessions/event (standard definition adults only and
pooled) vs 4 sessions/event (adults only and pooled, P o 0.001)
and 112 min/event (children only and pooled) vs 44 min/event
(adults only, P = 0.02) or 43 min/event (pooled, P o 0.001). Exercise
hypertension was more frequent among children/youth than
adults, when employing current standard definitions or as
reported in articles across all measures of exercise hypertension
(P o 0.001).
Exercise hypertension is a complex issue.8 In this population,
exercise hypertension is linked to abnormal cardiac and aortic
geometry and cardiac function (Grade 3A, 7 articles, n = 320) and
hypnoplasia of the transverse aortic arch (Grade 3A, 2 articles,
n = 54). However, individuals with aortic coarctation demonstrate
normal cardiac output responses to exercise (Grade 3A, 1 article,
n = 20). Medication may be required if exercise hypertension is
experienced (Grade 3A, 3 articles, n = 19) and the use of ACE
inhibitors may predict exercise hypertension (Grade 3A, 1 article,
n = 65). Exercise hypertension was not found to be associated with
re-coarctation (Grade 3A, 4 articles, n = 206) and to occur
independent of obstructions (Grade 3A, 1 article, n = 55). Exercise
hypertension was most prevalent among those with reduced
exercise capacity post surgery (Grade 3A, 1 article, n = 74). Mild
organ damage may still be experienced, even in the absence of
exercise hypertension (Grade 3A, 1 article, n = 20).
Exercise hypertension was associated with elevated systolic
blood pressures even at lower exercise workloads (Grade 3A, 1
article, n = 24) and elevated systolic blood pressure during daily
life (Grade 3A, 1 article, n = 144). Children/youth with coarctation
experiencing exercise hypertension demonstrated greater
increases in systolic blood pressure with maximal exercise
(Figure 4a): 74.8 ± 18.1 mm Hg vs 38.6 ± 11.1 mm Hg, P o 0.001.
Similarly, adults with coarctation experiencing exercise hyperten-
sion demonstrate greater increases in systolic blood pressure with
exercise (Figure 4b): 100.6 ± 35.2 vs 59.5 ± 20.7 mm Hg, P o 0.001.
Adults also demonstrated significantly greater increases in systolic
blood pressure with maximal exercise compared with children/
youth including those who experience exercise hypertension
(P o 0.001) and those who do not (Po 0.001).
Exercise testing among individuals with aortic coarctation was
found to be feasible (Grade 3A, 1 article, n = 46). Given the high

© 2017 Macmillan Publishers Limited, part of Springer Nature. Journal of Human Hypertension (2017), 1 – 8
 Aortic coarctation and physical activity
HJA Foulds et al
4
Figure 2. Exercise hypertension rates: prevalence (a), exercise sessions per event (b) and exercise minutes per event (c) among children/youth
with aortic coarctation. *Samples pooled with adult data where adult and children/youth data could not be separated.
rate of exercise hypertension among this population, blood
pressure should be monitored during exercise stress tests (Grade
3B, 1 article, n = 10). Post surgical repair of aortic coarctation,
exercise testing can be useful for determining the success of
surgery (Grade 3A, 3 articles, n = 82), exercise hypertension
experiences (Grade 3A, 5 articles, n = 192), blood pressure
gradients (Grade 3A, 1 article, n = 16) and for clarifying hemody-
namic status (Grade 3A, 1 article, n = 11). Exercise testing was
advocated long-term to identify secondary issues, such as ST
segment depressions and those at high risk of future cardiovas-
cular events (Grade 3A, 3 articles, n = 121).
Exercise testing was reported to be beneficial for determining
timing of surgery, particularly among patients who are borderline
candidates for surgical repair (Grade 3A, 1 article, n = 14).
Individuals who underwent surgical repair were found to have
similar exercise capacity post surgery to controls without aortic
coarctation (Grade 3A, 6 articles, n = 138). However, improvements
in exercise capacity post surgery were inconclusive, with some
reports of improved exercise capacity (Grade 3A, 1 article, n = 43)
and others reporting reduced exercise capacity (Grade 3A,
1 article, n = 260). The reported impacts of surgery on exercise
hypertension were also mixed, with some reports that surgery
does not reduce exercise hypertension (Grade 3A, 2 articles,
n = 63) and others reporting reduced exercise hypertension post
surgery (Grade 3A, 1 article, n = 31). However, exercise hyperten-
sion was reported to be most common in the first year post
surgery (Grade 3A, 1 article, n = 27) and only among those who
underwent surgery later in life (Grade 3A, 1 article, n = 15). Surgery
was found to improve hemodynamic responses to exercise in this
population (Grade 3A, 1 article, n = 21).
Maximal aerobic power was found to predict morbidity and
mortality in this population (Grade 3A, 1 article, n = 12). Adults
with a history of aortic coarctation were found to have low
Journal of Human Hypertension (2017), 1 – 8
exercise capacity, due to low physical activity levels (Grade 3A,
1 article, n = 103). Improving exercise capacity was recognized as
important for this population (Grade 3A, 2 articles, n = 363).
Individuals with aortic coarctation were found to have excessive
reliance on anaerobic metabolism during exercise (Grade 3A,
1 article, n = 15). Re-interventions were more common among
individuals with reduced exercise capacity (Grade 3A, 1 article,
n = 5). Exercise restrictions were inconclusively supported among
current literature. Individuals experiencing exercise hypertension
were recommended to avoid strenuous exercise (Grade 3A,
1 article, n = 28). However, exercise restrictions were found to
have no benefit for reducing mortality (Grade 3A, 1 article, n = 95).
DISCUSSION
The benefits of exercise for the general population are well
established; however, the benefits of exercise and need for
exercise restrictions among individuals with aortic coarctation are
unclear.1,14 This review evaluates the evidence of exercise on
individuals with aortic coarctation and outlines available evidence
of exercise benefits and risks associated among this population. As
identified in this review, there is a clear need for further research
in this area.
Reported adverse events in this population occurred in 2.6% of
exercise sessions among adults and 7.3% among children/youth
reporting adverse events, and 10.8% among adults and 33.0%
among children/youth of all exercise sessions when including
exercise hypertension as an adverse event. According to American
College of Sports Medicine stress testing guidelines, three
instances of absolute termination criteria were reported, repre-
senting 0.5% of all exercise stress tests.17 These overall rates are
high compared with other cardiac conditions, including atrial
fibrillation (0.5%) and malignant ventricular arrhythmias (12%);
© 2017 Macmillan Publishers Limited, part of Springer Nature.

Figure 3. Exercise hypertension rates: prevalence (a), exercise sessions per event (b) and exercise minutes per event (c) among adults with
aortic coarctation. *Samples pooled with children/youth data where adult and children/youth data could not be separated.
Figure 4. Changes in systolic blood pressure with exercise among
children/youth (a) and adults (b) with aortic coarctation experien-
cing and not experiencing exercise hypertension.
© 2017 Macmillan Publishers Limited, part of Springer Nature.
Aortic coarctation and physical activity
HJA Foulds et al
5
however, considering only absolute termination criteria, these
rates are similar or lower than other cardiac conditions.7,20 These
rates are based on small sample of articles and sixfold lower
breath of exercise minutes compared with previous reviews,
limiting the certainty of these adverse event rates.7 In addition,
this review could only evaluate exercise performed in aerobic
exercise stress tests, where exercise may be performed to higher
intensities than daily exercise. Further, many articles where
exercise hypertension could be determined did not report
specifically on other adverse events, potentially underestimating
overall adverse event rates. A range of criteria for exercise
hypertension also challenges these findings. Adverse event rates
determined in this review should be interpreted with caution until
further research is available and rates can be recalculated based
on larger sample sizes, greater reporting of adverse events other
than exercise hypertension, more consistent criteria of adverse
events and with the inclusion of exercise performed separate from
stress tests.
Exercise hypertension was commonly reported among this
population. The use of standard definitions of exercise hyperten-
sion is urgently needed. As indicated in this review, the rates of
exercise hypertension vary greatly depending on the definitions
employed. Among adults, exercise hypertension tends to be
overestimated without the use of standard definitions. More
concerning, exercise hypertension is often underestimated among
children/youth when standard definitions are not employed.
Among the general population and those with normal blood
pressure levels, experiences of exercise hypertension are asso-
ciated with increased incidence of cardiovascular morbidity and
mortality, including stroke and myocardial infarction, and all-cause
mortality.9–11 However, the associations of exercise hypertension
specific to individuals with aortic coarctation have not yet been
Journal of Human Hypertension (2017), 1 – 8
 Aortic coarctation and physical activity
HJA Foulds et al
6
evaluated. Among the general population, exercise hypertension
is suggested to predict future development of resting hyperten-
sion and has been associated with target organ damage and left
ventricular hypertrophy.21,22 Specific to individuals with aortic
coarctation, exercise hypertension has been associated with
abnormal cardiac geometry and function (Grade 3A, 7 articles,
n = 320). Associations of exercise hypertension and development
of resting hypertension among this population remain to be
examined.
The experience of exercise hypertension post-surgical repair of
aortic coarctation is mixed. Overall, surgical repair may be able to
reduce incidence of exercise hypertension and improve exercise
capacity and hemodynamic responses to exercise.23–25 Specifically,
studies identified exercise hypertension post surgery among those
who underwent surgery later in life, supporting surgery within the
first year of life as associated with fewer complications of aortic
coarctation.26 Exercise hypertension was also found to be greatest in
the first year post surgery, suggesting exercise hypertension may be
less prevalent following recovery from surgery.27 Exercise testing
may be valuable in the year following surgical repair to evaluate
changes in exercise hypertension experiences with recovery.
Evidence among the general population suggests individuals
with reduced aerobic exercise capacity may experience greater
morbidity and mortality.4–7 However, long-term associations of
exercise and exercise capacity specific to aortic coarctation are
currently lacking. Some investigations identified greater experi-
ences of exercise hypertension among individuals with lower
aerobic exercise capacity, including among individuals with aortic
coarctation.28,29. A possible association between greater incidence
of exercise hypertension and reduced aerobic exercise capacity
could result from increased cardiovascular and all-cause morbidity
and mortality associated with reduced exercise capacity and daily
physical activity.4–7,9–11 Increasing physical activity levels in this
population may therefore increase exercise capacity, reduce
experiences of exercise hypertension and improve long-term
prognosis.1,28,29 Conversely, associations of reduced exercise
capacity and increased exercise hypertension may be due to
worse pathology, which limits exercise capacity and results in
poorer outcomes and greater incidence of exercise
hypertension.27 The effectiveness and practicality of exercise as
part of a treatment program for worsened pathology among this
population has not been explored. Articles included in this review
identify individuals post-surgical repair as having similar exercise
capacity to that of control participants, suggesting individuals with
aortic coarctation are capable of normal levels of exercise
capacity.1,14 However, this has not been evaluated with reference
to the severity of pathology pre-surgery, as surgery early in life has
been associated with less experiences of exercise hypertension
post-surgery. Early intervention may result in less disease severity
and thus fewer limitations to exercise capacity.
Current exercise recommendations encourage exercise and
physical activity among individuals with aortic coarctation who do
not experience significant exercise hypertension or blood pressure
gradients.3 These recommendations are supported by changes in
systolic blood pressure with exercise identified among individuals
who experience exercise hypertension in this review. The greater
increase in systolic blood pressure among individuals who
experience exercise hypertension with maximal exercise likely
indicates greater experiences of increased systolic blood pressure
during daily activity and activity.30,31 The application of exercise
training to manage and treat this condition is not well understood;
however, low-to-moderate endurance exercise and exercise
training are encouraged among this population to prevent against
long-term complications and cardiovascular events.3 Research
evaluating safety and benefits of resistance training in this
population are not currently available. As many of these
individuals may experience exercise hypertension, current recom-
mendations suggest limiting resistance exercise to low or
Journal of Human Hypertension (2017), 1 – 8
moderate intensities among small muscle groups.3 Further
research is required to evaluate the use of exercise training to
reduce cardiovascular disease complications later in life and to
evaluate appropriate levels of resistance training in this
population.
Exercise stress tests are supported by this review for identifying
individuals experiencing exercise hypertension and other long-
term risks. The greater increase in systolic blood pressure among
individuals who experience exercise hypertension suggests resting
blood pressures may not accurately identify individuals who will
experience exercise hypertension. If exercise hypertension is
a consideration in recommendation of exercise restriction for
individuals in this population, exercise stress tests to determine
exercise hypertension are needed. Aerobic exercise stress tests are
also recommended for determining the success of surgery (Grade
3A, 5 articles, n = 192) and hemodynamic status (Grade 3A, 1
article, n = 11) post-surgical repair. The existence of blood pressure
gradients (Grade 3A, 1 article, n = 16) and indications of elevated
ambulatory blood pressure can also be indicated by exercise stress
tests (Grade 3A, 3 articles, n = 82). Long-term annual serial stress
tests are recommended for individuals with aortic coarctation to
assess long-term risks, particularly among individuals considered
high risk.32,33 Articles in this review did not evaluate exercise stress
test requirements; however, recommendations for exercise stress
testing currently exist.34,35 Exercise stress tests should be
conducted and supervised by trained operators, and testing
should include continuous electrocardiography, blood pressure
and pulse oximetry monitoring.34–36
Recommendations:
1. Aerobic exercise stress tests can be useful for evaluating exercise
hypertension, success of surgical repair and long-term prognosis.
Individuals with aortic coarctation should undergo regular
symptom-limited exercise stress tests under the supervision of
trained operators with continuous electrocardiography, blood
pressure and pulse oximetry monitoring to identify exercise
hypertension experiences and long-term cardiovascular
risks (3A).
2. Exercise training programs, daily exercise and physical activity
should be evaluated among this population. Evaluations of
exercise outcomes should include exercise hypertension
according to standardized definitions, and the incidence of all
other adverse events of exercise (4B).
3. Individuals who do not experience exercise hypertension,
exertional hypotension or other adverse events of exercise on
an aerobic stress test and do not have signs of left ventricular
hypertrophy, significant residual gradient at the coarctation site
or aortic or cerebral aneurysm can engage in regular moderate
intensity (40–85% VO2max) continuous aerobic exercise. These
individuals may also complete low or moderate intensity (o50%
maximal voluntary contraction) musculoskeletal exercise working
small muscle groups separately. Exercises with a high static
component and interval training should be avoided3 (4C).
4. Investigations and long-term follow-up studies should be
performed to evaluate the associations and risks of exercise
hypertension among individuals with aortic coarctation.
Associations of exercise hypertension and any increased
incidence of cardiovascular morbidity, including resting
hypertension, stroke and myocardial infarction, as well as
cardiovascular and all-cause morbidity should be
evaluated (4B).
Future directions
Further research evaluating exercise training and regular physical
activity among this population are urgently needed. The lack of
© 2017 Macmillan Publishers Limited, part of Springer Nature.

exercise training programs precludes the development of
evidence-based exercise recommendations or restrictions. Effec-
tively evaluating the benefits and risks of exercise among this
population requires further research. Long-term follow-ups
including exercise and/or physical activity are needed to
accurately evaluate exercise. Future studies should report all
adverse events of exercise in addition to exercise hypertension to
fully evaluate the risks associated with exercise in this population.
The risks and benefits associated with exercise should be re-
evaluated once further research is available.
This review is limited by the small sample of available literature
and small sample sizes of many investigations. Further, the lack of
exercise evaluations beyond aerobic stress tests further limits the
generalizability of these findings to daily life and exercise. The lack
of consistent definitions of exercise hypertension reported across
investigations limits the ability to identify exercise hypertension.
Definitions of exercise hypertension among children/youth are
also limited as percentiles of blood pressure with exercise across a
full age range of children/youth are not currently available. The
lack of reporting of adverse events among literature also limits the
accuracy of determined adverse event rates.
CONCLUSIONS
This review identifies clear needs for further research in this area.
Aerobic exercise stress testing was found to be valuable among
this population for evaluating risks of exercise, cardiovascular
events and long-term prognosis. There is a tremendous need and
opportunity for additional research to investigate the risks and
benefits of exercise among aortic coarctation. Particularly,
research evaluating exercise training programs, resistance exer-
cise, long-term cardiovascular, and all-cause morbidity and
mortality outcomes and associations of exercise, physical activity
and incidence of exercise hypertension, and the application of
exercise training as part of a treatment and management strategy
among this population are urgently needed.
What is known about the topic?
● Exercise is beneficial for general populations to reduce morbidity
and mortality.
● Aortic coarctation is a common congenital heart condition.
● Exercise among individuals with aortic coarctation could be
associated with increased risks of adverse events.
What this study adds?
● Exercise hypertension is common among individuals with aortic
coarctation, with children/youth experiencing much higher rates
than adults.
● Exercise stress tests can evaluate risks of exercise hypertension,
success of surgery and long-term prognosis.
● Further research is required to better evaluate exercise and potential
exercise restrictions among this population.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
This research was supported by funding from the Systematic Reviews Research Unit
at the University of British Columbia. This research was supported by the Canada
Foundation for Innovation, the BC Knowledge Development Fund, the Canadian
Institutes of Health Research (CIHR), the Michael Smith Foundation for Health
Research (MSFHR) and the Natural Sciences and Engineering Research Council of
Canada (NSERC). Dr Warburton was supported by a CIHR New Investigator Award and
© 2017 Macmillan Publishers Limited, part of Springer Nature.
Aortic coarctation and physical activity
HJA Foulds et al
7
a MSFHR Clinical Scholar Award. HF was supported by the University of
Saskatchewan.
REFERENCES
1 Buys R, Budts W, Delecluse C, Vanhees L. Exercise capacity, physical activity, and
obesity in adults with repaired aortic coarctation. J Cardiovasc Nursing 2013; 28(1):
66–73.
2 Banaszak P, Szkutnik M, Kusa J, Banaszak B, Bialkowski J. Utility of the dobutamine
stress echocardiography in the evaluation of the effects of a surgical repair of
aortic coarctation in children. Cardiol J 2009; 16(1): 20–25.
3 Takken T, Giardini A, Reybrouck T, Gewillig M, Hovels-Gurich HH, Longmuir PE
et al. Recommendations for physical activity, recreation sport, and exercise
training in paediatric patients with congenital heart disease: a report from the
Exercise, Basic & Translational Research Section of the European Association of
Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and
Lung Exercise Group, and the Association for European Paediatric Cardiology. Eur
J Prevent Cardiol 2012; 19(5): 1034–1065.
4 Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evi-
dence. Can Med Assoc J 2006; 174(6): 801–809.
5 Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons LW, Macera CA.
Changes in physical fitness and all-cause mortality. A prospective study of healthy
and unhealthy men. JAMA 1995; 273(14): 1093–1098.
6 Thomas SG, Goodman JM, Burr JF. Evidence-based risk assessment and recom-
mendations for physical activity clearance: established cardiovascular disease.
Appl Physiol 2011; 36(Suppl 1): S190–S213.
7 Giacomantonio NB, Bredin SS, Foulds HJ, Warburton DE. A systematic review of
the health benefits of exercise rehabilitation in persons living with atrial fibrilla-
tion. Can J Cardiol 2013; 29(4): 483–491.
8 De Caro E, Trocchio G, Smeraldi A, Calevo MG, Pongiglione G. Aortic arch geo-
metry and exercise-induced hypertension in aortic coarctation. Am J Cardiol 2007;
99(9): 1284–1287.
9 Weiss SA, Blumenthal RS, Sharrett AR, Redberg RF, Mora S. Exercise blood pressure
and future cardiovascular death in asymptomatic individuals. Circulation 2010;
121(19): 2109–2116.
10 Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen JT. Systolic blood
pressure response to exercise stress test and risk of stroke. Stroke 2001; 32(9):
2036–2041.
11 Laukkanen JA, Kurl S, Rauramaa R, Lakka TA, Venalainen JM, Salonen JT. Systolic
blood pressure response to exercise testing is related to the risk of acute myo-
cardial infarction in middle-aged men. Eur J Cardiovasc Prev Rehabil 2006; 13(3):
421–428.
12 Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA et al. Exercise
standards for testing and training: a scientific statement from the American Heart
Association. Circulation 2013; 128(8): 873–934.
13 Hacke C, Weisser B. Reference values for exercise systolic blood pressure in 12- to
17-year-old adolescents. Am J Hypertens 2016; 29(6): 747–753.
14 Hager A, Kanz S, Kaemmerer H, Hess J. Exercise capacity and exercise hyperten-
sion after surgical repair of isolated aortic coarctation. Am J Cardiol 2008; 101(12):
1777–1780.
15 Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E. Canadian clinical
practice guidelines on the management and prevention of obesity in adults and
children [summary]. Can Med Assoc J 2006; 176: S1–S13.
16 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-randomised studies of
health care interventions. J Epidemiol Commun Health 1998; 52(6): 377–384.
17 American College of Sports Medicine. In: Thompson WR, Gordon NF, Pescatello LS
(eds), ACSM’s Guidelines for Exercise Testing and Prescription, 8th edn, 400pp.
Lippincott Williams & Wilkins: Baltimore, MD, 2009.
18 Correia AS, Goncalves A, Paiva M, Sousa A, Oliveira SM, Lebreiro A et al. Long-term
follow-up after aortic coarctation repair: the unsolved issue of exercise-induced
hypertension. Rev Port Cardiol 2013; 32(11): 879–883.
19 Taylor SH, Donald KW. Circulatory studies at rest and during exercise in coarc-
tation of the aorta before and after operation. Br Heart J 1960; 22: 117–139.
20 Young DZ, Lampert S, Graboys TB, Lown B. Safety of maximal exercise testing in
patients at high risk for ventricular arrhythmia. Circulation 1984; 70(2): 184–191.
21 Sharabi Y, Ben-Cnaan R, Hanin A, Martonovitch G, Grossman E. The significance of
hypertensive response to exercise as a predictor of hypertension and cardio-
vascular disease. J Hum Hypertens 2001; 15(5): 353–356.
22 Farah R, Shurtz-Swirski R, Nicola M. High blood pressure response to stress
ergometry could predict future hypertension. Eur J Intern Med 2009; 20(4):
366–368.
23 Giordano U, Giannico S, Turchetta A, Hammad F, Calzolari F, Calzolari A. The
influence of different surgical procedures on hypertension after repair of coarc-
tation. Cardiol Young 2005; 15(5): 477–480.
Journal of Human Hypertension (2017), 1 – 8
 Aortic coarctation and physical activity
HJA Foulds et al
8
24 Connor TM, Baker WP. A comparison of coarctation resection and patch angio-
plasty using postexercise blood pressure measurements. Circulation 1981; 64(3):
567–572.
25 Murphy AM, Blades M, Daniels S, James FW. Blood pressure and cardiac output
during exercise: a longitudinal study of children undergoing repair of coarctation.
Am Heart J 1989; 117(6): 1327–1332.
26 Pelech AN, Kartodihardjo W, Balfe JA, Balfe JW, Olley PM, Leenen FH. Exercise in
children before and after coarctectomy: hemodynamic, echocardiographic, and
biochemical assessment. Am Heart J 1986; 112(6): 1263–1270.
27 Sigurdardottir LY, Helgason H. Exercise-induced hypertension after corrective
surgery for coarctation of the aorta. Pediatr Cardiol 1996; 17(5): 301–307.
28 Diller GP, Dimopoulos K, Okonko D, Li W, Babu-Narayan SV, Broberg CS et al.
Exercise intolerance in adult congenital heart disease: Comparative severity,
correlates, and prognostic implication. Circulation 2005; 112(6): 828–835.
29 Trojnarska O, Gwizdala A, Lanocha M, Katarzynska A, Katarzynski S,
Oko-Sarnowska Z et al. Exercise testing in adults after repair of aortic coarctation:
evaluation of cardiopulmonary exercise capacity and B-type natriuretic
protein levels. Texas Heart Inst J 2007; 34(4): 412–419.
30 Cyran SE, Grzeszczak M, Kaufman K, Weber HS, Myers JL, Gleason MM et al. Aortic
‘recoarctation’ at rest versus at exercise in children as evaluated by stress Doppler
echocardiography after a ‘good’ operative result. Am J Cardiol 1993; 71(11):
963–970.
Supplementary Information accompanies this paper on the Journal of Human Hypertension website (http://www.nature.com/jhh)
Journal of Human Hypertension (2017), 1 – 8
31 Vriend JW, van Montfrans GA, Romkes HH, Vliegen HW, Veen G, Tijssen JG et al.
Relation between exercise-induced hypertension and sustained hypertension in
adult patients after successful repair of aortic coarctation. J Hypertens 2004; 22(3):
501–509.
32 Kimball BP, Shurvell BL, Mildenberger RR, Houle S, McLaughlin PR. Abnormal
thallium kinetics in postoperative coarctation of the aorta: evidence for diffuse
hypertension-induced vascular pathology. J Am Coll Cardiol 1986; 7(3): 538–545.
33 Madueme PC, Khoury PR, Urbina EM, Kimball TR. Predictors of exaggerated
exercise-induced systolic blood pressures in young patients after
coarctation repair. Cardiol Young 2013; 23(3): 416–422.
34 Silversides CK, Kiess M, Beauchesne L, Bradley T, Connelly M, Niwa K et al.
Canadian Cardiovascular Society 2009 Consensus Conference on the manage-
ment of adults with congenital heart disease: outflow tract obstruction, coarcta-
tion of the aorta, tetralogy of Fallot, Ebstein anomaly and Marfan’s syndrome. Can
J Cardiol 2010; 26(3): e80–e97.
35 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin IJP, Guyton RA et al. AHA/
ACC guideline for the management of patients with valvular heart disease: Executive
summary: a report of the American College of Cardiology/American Heart Asso-
ciation Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63(22): 2438–2488.
36 Dahlbaeck O, Dahn I, Westling H. Hemodynamic observations in coarctation of
the aorta, with special reference to the blood pressure above and below the
stenosis at rest and during exercise. Scand J Clin Lab Invest 1964; 16: 339–346.
© 2017 Macmillan Publishers Limited, part of Springer Nature.