Advertisement
Mayo Clinic Proceedings Home

Exercising for Health and Longevity vs Peak Performance: Different Regimens for Different Goals

  • James H. O’Keefe
    Correspondence
    Correspondence: Address to James H. O’Keefe, MD, 4321 Washington St, Ste 2100, Kansas City, MO 64111.
    Affiliations
    Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO
    Search for articles by this author
  • Barry Franklin
    Affiliations
    Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, MI
    Oakland University William Beaumont School of Medicine, Rochester, MI
    Search for articles by this author
  • Carl J. Lavie
    Affiliations
    Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
    Department of Preventive Medicine, Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA
    Search for articles by this author
      Everything in excess is opposed to nature.Hippocrates

      Everything in excess is opposed to nature. Hippocrates. http://www.brainyquote.com/quotes/quotes/h/hippocrate118541.html. 2014. Accessed June 23, 2014.

      Accumulating evidence suggests that exercise practices that are ideal for promoting health and longevity may differ from the high-volume, high-intensity endurance training programs used for developing peak cardiac performance and superb cardiorespiratory fitness (CRF). Studies consistently show that regular moderate-intensity physical activity (PA) is highly beneficial for long-term cardiovascular (CV) health.
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      Improving the CRF from low to moderate to high will progressively improve CV prognosis and overall survival.
      • Swift D.L.
      • Lavie C.J.
      • Johannsen N.M.
      • et al.
      Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.
      However, the survival benefits from improvements in the CRF plateau at about 10 metabolic equivalents (with 1 metabolic equivalent equal to an oxygen consumption of 3.5 mL O2/kg body weight per minute), with no additional survival benefit accruing from higher CRF levels.
      • Swift D.L.
      • Lavie C.J.
      • Johannsen N.M.
      • et al.
      Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.
      • Blair S.N.
      • Kohl III, H.W.
      • Paffenbarger Jr., R.S.
      • Clark D.G.
      • Cooper K.H.
      • Gibbons L.W.
      Physical fitness and all-cause mortality: a prospective study of healthy men and women.
      • Kokkinos P.
      • Myers J.
      Exercise and physical activity: clinical outcomes and applications.
      Clearly, 30 minutes of regular vigorous PA enhances health and well-being, but performing 3-hour bouts of strenuous PA does not multiply the health benefits. Indeed, recent studies suggest that extreme exercise may evoke acute elevations in cardiac troponin I and B-type natriuretic peptide and evidence of transient myocardial dysfunction.
      • Trivax J.E.
      • Franklin B.A.
      • Goldstein J.A.
      • et al.
      Acute cardiac effects of marathon running.
      • Mohlenkamp S.
      • Leineweber K.
      • Lehmann N.
      • et al.
      Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners.
      “Cardiac overuse injury” is the term we have suggested for this increasingly common consequence of the “more exercise is better” strategy.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      Many seasoned endurance athletes have experience with orthopedic overuse injuries such as plantar fasciitis, Achilles tendonitis, shin splints, and patellar chondromalacia. However, cardiac overuse injury may be associated with more ominous outcomes, including threatening cardiac arrhythmias, accelerated coronary plaque formation, premature aging of the heart, myocardial fibrosis, plaque rupture and acute coronary thrombosis, and even sudden cardiac death.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.

      Exercise and Survival: The Reverse J-Curve Pattern

      Williams and Thompson,
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      reporting in the current issue of the Mayo Clinic Proceedings, used the National Walkers’ and Runners’ Health Studies database, through which they followed 2377 survivors of myocardial infarction to assess the dose-response relation between exercise and CV disease–related mortality during long-term follow-up. Chronic running or walking was associated with progressively lower CV mortality risks up to a point, beyond which much of the benefit of exercise on CV longevity was lost (in a reverse J-curve pattern). Remarkable dose-dependent reductions of up to 65% in CV mortality were seen among cohorts who were running less than 30 miles (50 km) per week, or walking less than 46 miles (75 km) per week. Of interest, this study confirmed previous reports showing that the CV benefits of walking and running were equivalent as long as the energy expenditures were the same (though when walking, as compared to running, it will take about twice as long to burn the same number of calories).
      Very recently, a similar reverse J-curve pattern was described in a German cohort study of 1038 individuals with stable coronary heart disease (CHD).
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      The 2 major findings that emerged from their data set were the same as those reported by Williams and Thompson
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      : (1) physically inactive individuals were at the highest risk for adverse health outcomes and (2) the most physically active group (those doing strenuous PA on a daily basis) was at an increased risk of CV mortality compared with moderately active individuals. During this 10-year study, the most sedentary group was at 2-fold increased risk for myocardial infarction or stroke and 4-fold increased risk of death compared with the moderately active group. However, the individuals who performed strenuous exercise on a daily basis were also about twice as likely to die of myocardial infarction or stroke compared with the moderately active individuals.
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      Epidemiological studies focusing on healthy populations have reported similar reverse J-curve or U-curve patterns for exercise and long-term outcomes.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.
      • O’Keefe J.H.
      • Patil H.
      • Magalski A.
      • Lavie C.J.
      • Vogel R.A.
      • McCullough P.A.
      Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
      Moderate exercise, as compared with physical inactivity, markedly reduces the risk of both CV and all-cause mortality.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.
      • O’Keefe J.H.
      • Patil H.
      • Magalski A.
      • Lavie C.J.
      • Vogel R.A.
      • McCullough P.A.
      Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
      However, at the more extreme levels of chronic endurance exercise (generally high-mileage running), there is the potential for a plateau or even a decline in benefit, with heightened risks for both musculoskeletal and CV complications. A very recent study of more than 55,000 individuals, including more than 13,000 runners, followed for more than 15 years, found that runners compared with nonrunners had reductions in all-cause mortality and CV mortality by 30% and 45%, respectively, though slight reverse J-shaped curves were again apparent.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      The maximal benefits were noted at moderate mileage and moderate speeds, and exercise frequencies of fewer than 6 d/wk.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      Collectively, the data suggest that moderate doses of exercise are sufficient for conferring optimal CV and longevity benefits and very high doses of PA appear to offer little or no additional survival benefit.
      • Löllgen H.
      • Böckenhoff A.
      • Knapp G.
      Physical activity and all-cause mortality: an updated meta-analysis with different intensity categories.
      The hypothetical upper dose limit for safe exercise remains unclear, but generally keeping the intensity, frequency, and duration of exercise all in the moderate ranges may be important for maximizing health and longevity benefits.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.
      • O’Keefe J.H.
      • Patil H.
      • Magalski A.
      • Lavie C.J.
      • Vogel R.A.
      • McCullough P.A.
      Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      • La Gerche A.
      • Prior D.L.
      Exercise–is it possible to have too much of a good thing?.
      • Vuori I.M.
      • Lavie C.J.
      • Blair S.N.
      Physical activity promotion in the health care system.
      • Franklin B.A.
      • Lavie C.J.
      • Squires R.W.
      • Milani R.V.
      Exercise-based cardiac rehabilitation and improvements in cardiorespiratory fitness: implications regarding patient benefit.

      Exercise and Atrial Fibrillation

      Many epidemiological and observational studies have reported a strong statistically significant association between chronic high-intensity aerobic exercise and a heightened risk of developing atrial fibrillation (AF).
      • Andersen K.
      • Farahmand B.
      • Ahlbom A.
      • et al.
      Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study.
      • Menezes A.R.
      • Lavie C.J.
      • DiNicolantonio J.J.
      • et al.
      Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      • Mozaffarian D.
      • Furberg C.D.
      • Psaty B.M.
      • Siscovick D.
      Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study.
      The impact of habitual PA on the risk of AF, like the risk of mortality, appears to also be nonlinear. Compared with sedentary individuals, lower rates of AF have been noted among the moderately active, whereas higher rates are seen among individuals performing excessive amounts of vigorous, high-intensity exercise in the long term.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      • Mozaffarian D.
      • Furberg C.D.
      • Psaty B.M.
      • Siscovick D.
      Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study.
      A recent, large study used a population-based cohort design to evaluate the link between PA and the risk of AF among 44,410 Swedish men.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      The authors found that intense exercise of more than 5 h/wk at age 30 years increased the risk of developing AF later in life. In contrast, moderate-intensity PA, such as walking or bicycling, in middle age decreased the risk of AF.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      Similarly, a prospective observational study of older men and women (mean age 73 years) reported that moderate-intensity PA such as walking reduced the risk for AF by about one-third.
      • Mozaffarian D.
      • Furberg C.D.
      • Psaty B.M.
      • Siscovick D.
      Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study.
      Still, exercise intensity in that study showed the familiar reverse J-shaped relationship with the risk of AF (Figure 1). Another large cohort study, this one evaluating 52,755 long-distance cross-country skiers competing in an annual 90-km race in Sweden, found higher rates of arrhythmias including AF among the men and women who had the (1) greatest number of completed cross-country races and (2) fastest finishing times.
      • Andersen K.
      • Farahmand B.
      • Ahlbom A.
      • et al.
      Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study.
      Fortunately, much of the risk for AF seems to resolve with detraining and moderation of the exercise dose, probably in part because of the normalization of the autonomic tone.
      • Wilhelm M.
      • Roten L.
      • Tanner H.
      • Wilhelm I.
      • Schmid J.P.
      • Saner H.
      Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes.
      Figure thumbnail gr1
      Figure 1Risk of new-onset atrial fibrillation among 5446 older adults (>65 years) as a function of exercise intensity.
      • Mozaffarian D.
      • Furberg C.D.
      • Psaty B.M.
      • Siscovick D.
      Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study.

      Health Dividends from Sports Stardom

      Also in this issue of the Mayo Clinic Proceedings, Garatachea et al
      • Garatachea N.
      • Santos-Lozano A.
      • Sanchis-Gomar F.
      • Pareja-Galeano H.
      • Emanuele E.
      • Lucia A.
      Former elite athletes live longer than the general population: a meta-analysis.
      present a meta-analysis of long-term health outcomes in former top-level athletes, noting that they tend to live longer than the general population and have lower mortality rates for both CV disease and cancer. Thus, they conclude that previous intense exercise does not seem to adversely affect longevity. However, the analysis was plagued by numerous methodological limitations. For example, the studies they analyzed included athletes from varied sports ranging from professional baseball and the National Football League (American football) to soccer, cycling, and certain Olympic events. Many of these sports do not involve sustained intense aerobic efforts, which is the specific pattern of exercise that has raised concerns about cardiac overuse injury. Second, professional athletes are typically in their 20s when the somatic and CV systems are most resilient to stresses induced by intense exercise. Most of these athletes probably markedly reduced their PA levels when they retired from their sport. Third, top-level athletes tend to be physically gifted, health-conscious individuals who tend to enjoy exercise and understand the importance of healthy diet and the avoidance of tobacco smoking, all of which promote longevity. Finally, society bestows on professional athletes and Olympic heroes high socioeconomic status, which is strongly associated with better health and superior longevity. Indeed, winners of a Nobel Prize or an Oscar Award have also been shown to have superior life expectancy as compared with the general population.
      • Han X.
      • Small D.S.
      • Foster D.P.
      • Patel V.
      The effect of winning an Oscar Award on survival: correcting for healthy performer survivor bias with a rank preserving structural accelerated failure time model.
      • Rablen M.D.
      • Oswald A.J.
      Mortality and immortality: the Nobel Prize as an experiment into the effect of status upon longevity.
      Although the study by Garatachea et al
      • Garatachea N.
      • Santos-Lozano A.
      • Sanchis-Gomar F.
      • Pareja-Galeano H.
      • Emanuele E.
      • Lucia A.
      Former elite athletes live longer than the general population: a meta-analysis.
      cannot be used to completely exonerate chronic extreme endurance exercise, it at least reassures us that previous high-level physical exertion among young elite athletes does not seem to adversely affect their life expectancy.

      Marathon Running and CHD

      The number of Americans participating in marathons has increased 25-fold over the past 40 years.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      Despite the favorable risk factor profiles and extraordinary CRF of long-distance runners, race-related cardiac fatalities in marathon runners are reported each year.
      • Kim J.H.
      • Malhotra R.
      • Chiampas G.
      • et al.
      for the Race Associated Cardiac Arrest Event Registry (RACER) Study Group
      Cardiac arrest during long-distance running races.
      In addition, the running study by Lee et al
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      discussed above found that higher running doses were associated with higher levels of CRF, but this did not translate into better CV or all-cause survival (which peaked at low-dose exercise). Paradoxically, long-term marathon running has in some studies been associated with increased, not decreased, coronary plaque development. Schwartz et al
      • Schwartz R.S.
      • Merkel Kraus S.
      • Schwartz J.G.
      • Wickstrom K.K.
      • et al.
      Increased coronary artery plaque volume among male marathon runners.
      found by using coronary angiography that compared with sedentary, age-matched controls, veteran male endurance runners (who had run at least 1 marathon each year for 25 consecutive years) had significantly increased amounts of coronary plaque, both hard and soft (Figure 2).
      Figure thumbnail gr2
      Figure 2Male marathoners had significantly more total coronary plaque volume, noncalcified plaque volume, and calcified plaque volume than did sedentary controls.
      • Schwartz R.S.
      • Merkel Kraus S.
      • Schwartz J.G.
      • Wickstrom K.K.
      • et al.
      Increased coronary artery plaque volume among male marathon runners.
      Using CV magnetic resonance imaging, Trivax et al
      • Trivax J.E.
      • Franklin B.A.
      • Goldstein J.A.
      • et al.
      Acute cardiac effects of marathon running.
      reported that marathon running causes acute dilation of the right atrium and the right ventricle, reduction in the right ventricular ejection fraction, and elevations in cardiac troponin I and B-type natriuretic peptide—possible harbingers of adverse long-term CV sequelae, including fibrosis. About 50% of the runners will have an abnormally elevated troponin level after a marathon; these individuals are more likely to have myocardial fibrosis than do marathoners with normal postrace troponin levels.
      • Mohlenkamp S.
      • Leineweber K.
      • Lehmann N.
      • et al.
      Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners.
      Moreover, in this study, higher coronary artery calcium scores and myocardial fibrosis were associated with higher CHD event rates during follow-up.
      • Mohlenkamp S.
      • Leineweber K.
      • Lehmann N.
      • et al.
      Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners.

      Optimal Dosing of Exercise

      From a population-wide perspective, physical inactivity is a much more prevalent public health problem than excessive exercise. The Physical Activity Guidelines for Americans call for 150 min/wk or more of moderate-intensity aerobic PA or 75 min/wk of vigorous-intensity aerobic PA.
      Centers for Disease Control and Prevention (CDC)
      Adult participation in aerobic and muscle-strengthening physical activities–United States, 2011.
      A recent survey of a half million adults in the United States reported that about 10 of every 20 people fail to obtain this suggested minimum weekly dose of PA.
      Centers for Disease Control and Prevention (CDC)
      Adult participation in aerobic and muscle-strengthening physical activities–United States, 2011.
      However, extrapolation of the data from the current Williams and Thompson
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      study to the general population would suggest that approximately 1 of 20 people is overdoing exercise, potentially increasing the risk-to-benefit ratio. Individuals from either end of the exercise spectrum (sedentary people and overexercisers) would probably reap long-term health benefits by changing their PA levels to be in the moderate range.
      Exercise is unparalleled for its ability to improve CV health, quality of life, and overall longevity. If the current mantra “exercise is medicine” is embraced, PA might be best analogized as a drug, with indications and contraindications, as well as issues related to underdosing and overdosing. As with any powerful therapy, establishing the safe and effective dose range is fundamentally important—an insufficiently low dose may not bestow full benefits, whereas an overdose may produce dangerous adverse effects that outweigh its benefits. Fortunately, the exercise dose-response range that is safe and effective for improving CV health and longevity is broad. Although there is a concerted, research-based effort to reduce physical inactivity and prolonged periods of sitting, increasing data regarding the other end of the exercise continuum now suggest that it may be possible to have too much of a good thing.
      • La Gerche A.
      • Prior D.L.
      Exercise–is it possible to have too much of a good thing?.
      On the basis of multiple studies, it might be prudent to limit chronic vigorous exercise to no more than about 60 min/d.
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      This recommendation is reinforced by a trial of 60 men with stable CHD who were randomized to vigorous exercise sessions lasting either 30 or 60 minutes.
      • Michaelides A.P.
      • Soulis D.
      • Antoniades C.
      • et al.
      Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.
      The 30-minute exercise bouts enhanced arterial elasticity and generated minimal oxidant stress. In contrast, the 60-minute sessions amplified oxidant stress and transiently stiffened blood vessels, especially among men older than 50 years.
      • Michaelides A.P.
      • Soulis D.
      • Antoniades C.
      • et al.
      Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.
      A weekly cumulative dose of vigorous exercise of not more than about 5 hours has been identified in several studies to be the safe upper range for long-term CV health and life expectancy.
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.
      • O’Keefe J.H.
      • Patil H.
      • Magalski A.
      • Lavie C.J.
      • Vogel R.A.
      • McCullough P.A.
      Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      • Michaelides A.P.
      • Soulis D.
      • Antoniades C.
      • et al.
      Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.
      It may also be beneficial to take 1 or 2 days a week off from vigorous exercise and to refrain from high-intensity exercise on a daily basis.
      • Williams P.
      • Thompson P.
      Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
      • Mons U.
      • Hahmann H.
      • Brenner H.
      A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
      • O’Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.M.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise.
      • O’Keefe J.H.
      • Lavie C.J.
      Run for your life … at a comfortable speed and not too far.
      • O’Keefe J.H.
      • Schnohr P.
      • Lavie C.J.
      The dose of running that best confers longevity.
      • O’Keefe J.H.
      • Patil H.
      • Magalski A.
      • Lavie C.J.
      • Vogel R.A.
      • McCullough P.A.
      Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
      • Lee D.-C.
      • Pate R.R.
      • Lavie C.J.
      • Sui X.
      • Church T.S.
      • Blair S.N.
      Leisure-time running reduces all-cause and cardiovascular mortality risk.
      • Drca N.
      • Wolk A.
      • Jensen-Urstad M.
      • Larsson S.C.
      Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
      “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health,”

      Everything in excess is opposed to nature. Hippocrates. http://www.brainyquote.com/quotes/quotes/h/hippocrate118541.html. 2014. Accessed June 23, 2014.

      Hippocrates stated more than 2000 years ago, and we believe this assessment continues to provide wise guidance.

      Supplemental Online Material

      References

      1. Everything in excess is opposed to nature. Hippocrates. http://www.brainyquote.com/quotes/quotes/h/hippocrate118541.html. 2014. Accessed June 23, 2014.

        • Williams P.
        • Thompson P.
        Increased cardiovascular disease mortality from excessive exercise in heart attack survivors.
        Mayo Clin Proc. 2014; 89: 1187-1194
        • Mons U.
        • Hahmann H.
        • Brenner H.
        A reverse J-shaped association of leisure time physical activity with prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurements.
        Heart. 2014; 100: 1043-1049
        • O’Keefe J.H.
        • Patil H.R.
        • Lavie C.J.
        • Magalski A.M.
        • Vogel R.A.
        • McCullough P.A.
        Potential adverse cardiovascular effects from excessive endurance exercise.
        Mayo Clin Proc. 2012; 87: 587-595
        • Swift D.L.
        • Lavie C.J.
        • Johannsen N.M.
        • et al.
        Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.
        Circ J. 2013; 77: 281-292
        • Blair S.N.
        • Kohl III, H.W.
        • Paffenbarger Jr., R.S.
        • Clark D.G.
        • Cooper K.H.
        • Gibbons L.W.
        Physical fitness and all-cause mortality: a prospective study of healthy men and women.
        JAMA. 1989; 262: 2395-2401
        • Kokkinos P.
        • Myers J.
        Exercise and physical activity: clinical outcomes and applications.
        Circulation. 2010; 122: 1637-1648
        • Trivax J.E.
        • Franklin B.A.
        • Goldstein J.A.
        • et al.
        Acute cardiac effects of marathon running.
        J Appl Physiol. 2010; 108: 1148-1153
        • Mohlenkamp S.
        • Leineweber K.
        • Lehmann N.
        • et al.
        Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners.
        Basic Res Cardiol. 2014; 109: 391
        • O’Keefe J.H.
        • Lavie C.J.
        Run for your life … at a comfortable speed and not too far.
        Heart. 2013; 99: 516-519
        • O’Keefe J.H.
        • Schnohr P.
        • Lavie C.J.
        The dose of running that best confers longevity.
        Heart. 2013; 99: 588-590
        • O’Keefe J.H.
        • Patil H.
        • Magalski A.
        • Lavie C.J.
        • Vogel R.A.
        • McCullough P.A.
        Reply to letter to the editor: potential, but unobserved, adverse cardiovascular effects from endurance exercise.
        Mayo Clin Proc. 2012; 87: 1133-1134
        • Lee D.-C.
        • Pate R.R.
        • Lavie C.J.
        • Sui X.
        • Church T.S.
        • Blair S.N.
        Leisure-time running reduces all-cause and cardiovascular mortality risk.
        J Am Coll Cardiol. 2014; 64: 472-481
        • Löllgen H.
        • Böckenhoff A.
        • Knapp G.
        Physical activity and all-cause mortality: an updated meta-analysis with different intensity categories.
        Int J Sports Med. 2009; 30: 213-224
        • La Gerche A.
        • Prior D.L.
        Exercise–is it possible to have too much of a good thing?.
        Heart Lung Circ. 2007; 16: S102-S104
        • Vuori I.M.
        • Lavie C.J.
        • Blair S.N.
        Physical activity promotion in the health care system.
        Mayo Clin Proc. 2013; 88: 1446-1461
        • Franklin B.A.
        • Lavie C.J.
        • Squires R.W.
        • Milani R.V.
        Exercise-based cardiac rehabilitation and improvements in cardiorespiratory fitness: implications regarding patient benefit.
        Mayo Clin Proc. 2013; 88: 431-437
        • Andersen K.
        • Farahmand B.
        • Ahlbom A.
        • et al.
        Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study.
        Eur Heart J. 2013; 34: 3624-3631
        • Menezes A.R.
        • Lavie C.J.
        • DiNicolantonio J.J.
        • et al.
        Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies.
        Mayo Clin Proc. 2013; 88: 394-409
        • Drca N.
        • Wolk A.
        • Jensen-Urstad M.
        • Larsson S.C.
        Atrial fibrillation is associated with different levels of physical activity levels at different ages in men.
        Heart. 2014; 100: 1037-1042
        • Mozaffarian D.
        • Furberg C.D.
        • Psaty B.M.
        • Siscovick D.
        Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study.
        Circulation. 2008; 118: 800-807
        • Wilhelm M.
        • Roten L.
        • Tanner H.
        • Wilhelm I.
        • Schmid J.P.
        • Saner H.
        Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes.
        Am J Cardiol. 2011; 108: 580-585
        • Garatachea N.
        • Santos-Lozano A.
        • Sanchis-Gomar F.
        • Pareja-Galeano H.
        • Emanuele E.
        • Lucia A.
        Former elite athletes live longer than the general population: a meta-analysis.
        Mayo Clin Proc. 2014; 89: 1195-1200
        • Han X.
        • Small D.S.
        • Foster D.P.
        • Patel V.
        The effect of winning an Oscar Award on survival: correcting for healthy performer survivor bias with a rank preserving structural accelerated failure time model.
        Ann Appl Stat. 2011; 5: 746-772
        • Rablen M.D.
        • Oswald A.J.
        Mortality and immortality: the Nobel Prize as an experiment into the effect of status upon longevity.
        J Health Econ. 2008; 27: 1462-1471
        • Kim J.H.
        • Malhotra R.
        • Chiampas G.
        • et al.
        • for the Race Associated Cardiac Arrest Event Registry (RACER) Study Group
        Cardiac arrest during long-distance running races.
        N Engl J Med. 2012; 366: 130-140
        • Schwartz R.S.
        • Merkel Kraus S.
        • Schwartz J.G.
        • Wickstrom K.K.
        • et al.
        Increased coronary artery plaque volume among male marathon runners.
        Missouri Med. 2014; 111: 85-90
        • Centers for Disease Control and Prevention (CDC)
        Adult participation in aerobic and muscle-strengthening physical activities–United States, 2011.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 326-330
        • Michaelides A.P.
        • Soulis D.
        • Antoniades C.
        • et al.
        Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.
        Heart. 2011; 97: 832-837

      Linked Article