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Grand Rounds

Is There Such a Thing as Too Much Cardiorespiratory Fitness When it Comes to Mortality?

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BACKGROUND AND PURPOSE: 

  • There is strong evidence that cardiorespiratory fitness is inversely associated with mortality, regardless of age, sex, race/ethnicity and comorbidies  
  • However, there is some literature to suggest that habitual vigorous exercise may not result in lower mortality risk and may even be associated with harms  
    • ‘Plateau effect’ where there is no longer an inverse association with mortality risk  
  • Mandsager et al. (JAMA Network Open 2018) sought to determine whether cardiorespiratory fitness is associated with all-cause mortality and whether there is an intensity threshold

METHODS: 

  • Retrospective cohort  
    • Individuals at a tertiary care academic medical center 
    • Adult patients undergoing a stress test 
    • Symptom-limited exercise treadmill testing  
  • Cardiorespiratory fitness: Quantified by peak estimated metabolic equivalents on treadmill testing 
  • Performance groups  
    • Low (<25th percentile) 
    • Below average (25th-49th percentile) 
    • Above average (50th-74th percentile) 
    • High (75th-97.6th percentile) 
    • Elite (≥97.7th percentile) 
  • Patients stratified by age and sex 
  • Main outcome: All-cause mortality

RESULTS: 

  • 122,007patients were included 
    • 40.8% women  
    • Mean age: 53.4 years 
    • 1.1 million person-years of observation 
  • Risk-adjusted all-cause mortality was inversely proportional to cardiorespiratory fitness and was lowest in elite performers 
    • Elite vs low: Adjusted hazard ratio (aHR) 0.20 (95% CI, 0.16-0.24; P < .001) 
    • Elite vs high: aHR 0.77 (95% CI, 0.63-0.95; P = .02) 
  • Low cardiorespiratory fitness was associated with increased mortality  
    • Low vs elite: aHR 5.04 (95% CI, 4.10-6.20; P < .001)  
    • Below average vs above average: aHR 1.41 (95% CI, 1.34-1.49; P < .001)  

Subgroup analysis:  

  • Benefit of elite vs high cardiorespiratory fitness was seen in the overall cohort, but when broken out by age, benefit was only seen in older adults ≥70 years 
    • Elite over high performance: aHR 0.71 (95% CI, 0.52-0.98; P = .04)  
  • Benefit seen in all comorbidity groups and in patients with hypertension there was significant difference 
    • Elite over high performance: aHR 0.70 (95% CI, 0.50-0.99; P = .05) 
  • Extreme cardiorespiratory fitness (≥2 SDs above the mean for age and sex) was associated with the lowest risk-adjusted all-cause mortality compared with all other performance groups

CONCLUSION: 

  • The increase in all-cause mortality associated with reduced cardiorespiratory fitness was greater than or equal to traditional clinical risk factors such as smoking, diabetes and coronary artery disease  
  • There was no observed upper limit of benefit associated cardiorespiratory fitness 
  • High/extreme levels of fitness in older individuals may reflect long-term habits and have a cumulative effect

Learn More – Primary Sources: 

Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults Undergoing Exercise Treadmill Testing

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Related ObG Topics:

The Relationship between Exercise and Heart Disease – Does Genetics Matter?
Is Midlife Cardiovascular Fitness Associated with Reduced Risk for Dementia?
How Does Exercise Affect Health Postmenopause?
Age and Gait: When Do We Really Start Slowing Down?

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