Advertisement
Mayo Clinic Proceedings Home

Increased Cardiovascular Disease Mortality Associated With Excessive Exercise in Heart Attack Survivors

      Abstract

      Objective

      To test whether greater exercise is associated with progressively lower mortality after a cardiac event.

      Patients and Methods

      We used Cox proportional hazard analyses to examine mortality vs estimated energy expended by running or walking measured as metabolic equivalents (3.5 mL O2/kg per min per day or metabolic equivalent of task-h/d [MET-h/d]) in 2377 self-identified heart attack survivors, where 1 MET-h/d is the energy equivalent of running 1 km/d. Mortality surveillance via the National Death Index included January 1991 through December 2008.

      Results

      A total of 526 deaths occurred during an average prospective follow-up of 10.4 years, 376 (71.5%) of which were related to cardiovascular disease (CVD) (International Statistical Classification of Diseases, 10th Revision codes I00-I99). CVD-related mortality compared with the lowest exercise group decreased by 21% for 1.07 to 1.8 MET-h/d of running or walking (P=.11), 24% for 1.8 to 3.6 MET-h/d (P=.04), 50% for 3.6 to 5.4 MET-h/d (P=.001), and 63% for 5.4 to 7.2 MET-h/d (P<.001) but decreased only 12% for ≥7.2 MET-h/d (P=.68). These data represent a 15% average risk reduction per MET-h/d for CVD-related mortality through 7.2 MET-h/d (P<.001) and a 2.6-fold risk increase above 7.2 MET-h/d (P=.009). Relative to the risk reduction at 7.2 MET-h/d, the risk for ≥7.2 MET-h/d increased 3.2-fold (P=.006) for all ischemic heart disease (IHD)–related mortalities but was not significantly increased for non–IHD-CVD, arrhythmia-related CVD, or non–CVD-related mortalities.

      Conclusion

      Running or walking decreases CVD mortality risk progressively at most levels of exercise in patients after a cardiac event, but the benefit of exercise on CVD mortality and IHD deaths is attenuated at the highest levels of exercise (running: above 7.1 km/d or walking briskly: 10.7 km/d).

      Abbreviations and Acronyms:

      CVD (cardiovascular disease), HR (hazard ratio), ICD-10 (International Statistical Classification of Diseases, 10th Revision), IHD (ischemic heart diasease), MET-h/d (metabolic equivalent of task-h/d)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Physical Activity Guidelines Advisory Committee
        Physical Activity Guidelines Advisory Committee Report, 2008.
        US Department of Health and Human Services, Washington, DC2008 (A1-H14)
        • Williams P.T.
        Reductions in incident coronary heart disease risk above guideline physical activity levels in men.
        Atherosclerosis. 2010; 209: 524-527
        • Haskell W.L.
        • Lee I.M.
        • Pate R.R.
        • et al.
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Med Sci Sports Exerc. 2007; 39: 1423-1434
        • Siscovick D.S.
        • Weiss N.S.
        • Fletcher R.H.
        • Lasky T.
        The incidence of primary cardiac arrest during vigorous exercise.
        N Engl J Med. 1984; 311: 874-877
        • Giri S.
        • Thompson P.D.
        • Kiernan F.J.
        • et al.
        Clinical and angiographic characteristics of exertion-related acute myocardial infarction.
        JAMA. 1999; 282: 1731-1736
        • Albert C.M.
        • Mittleman M.A.
        • Chae C.U.
        • Lee I.M.
        • Hennekens C.H.
        • Manson J.E.
        Triggering of sudden death from cardiac causes by vigorous exertion.
        N Engl J Med. 2000; 343: 1355-1361
        • Lavie C.J.
        • Thomas R.J.
        • Squires R.W.
        • Allison T.G.
        • Milani R.V.
        Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease.
        Mayo Clin Proc. 2009; 84: 373-383
        • Mann N.
        • Rosenzweig A.
        Can exercise teach us how to treat heart disease?.
        Circulation. 2012; 126: 2625-2635
        • Thompson P.D.
        • Franklin B.A.
        • Balady G.J.
        • et al.
        • American Heart Association Council on Nutrition, Physical Activity, and Metabolism; American Heart Association Council on Clinical Cardiology; American College of Sports Medicine
        Exercise and acute cardiovascular events placing the risks into perspective. A scientific statement from the AHA Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology.
        Circulation. 2007; 115: 2358-2368
        • O'Keefe J.H.
        • Patil H.R.
        • Lavie C.J.
        • Magalski A.
        • Vogel R.A.
        • McCullough P.A.
        Potential adverse cardiovascular effects from excessive endurance exercise.
        Mayo Clin Proc. 2012; 87: 587-595
        • Ector J.
        • Ganame J.
        • van der Merwe N.
        • et al.
        Reduced right ventricular ejection fraction in endurance athletes presenting with ventricular arrhythmias: a quantitative angiographic assessment.
        Eur Heart J. 2007; 28: 345-353
        • Spirito P.
        • Pelliccia A.
        • Proschan M.A.
        • et al.
        Morphology of the “athlete's heart” assessed by echocardiography in 947 elite athletes representing 27 sports.
        Am J Cardiol. 1994; 74: 802-806
        • Jensen-Urstad K.
        • Bouvier F.
        • Saltin B.
        • Jensen-Urstad M.
        High prevalence of arrhythmias in elderly male athletes with a lifelong history of regular strenuous exercise.
        Heart. 1998; 79: 161-164
        • Mont L.
        • Elosua R.
        • Brugada J.
        Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter.
        Europace. 2009; 11: 11-17
        • Whyte G.P.
        • Sheppard M.
        • George K.P.
        • et al.
        Arrhythmias and the athlete: mechanisms and clinical significance.
        Eur Heart J. 2007; 28 (author reply 1401): 1399-1401
        • Möhlenkamp S.
        • Lehmann N.
        • Breuckmann F.
        • et al.
        • Marathon Study Investigators; Heinz Nixdorf Recall Study Investigators
        Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners.
        Eur Heart J. 2008; 29: 1903-1910
        • 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.
        • Lavie C.J.
        Run for your life… at a comfortable speed and not too far.
        Heart. 2013; 99: 516-519
        • Breuckmann F.
        • Möhlenkamp S.
        • Nassenstein K.
        • et al.
        Myocardial late gadolinium enhancement: prevalence, pattern, and prognostic relevance in marathon runners.
        Radiology. 2009; 251: 50-57
        • La Gerche A.
        • Burns A.T.
        • Mooney D.J.
        • et al.
        Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes.
        Eur Heart J. 2012; 33: 998-1006
        • Wilson M.
        • O'Hanlon R.
        • Prasad S.
        • et al.
        Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes.
        J Appl Physiol (1985). 2011; 110: 1622-1626
        • Williams P.T.
        Walking and running produce similar reductions in cause-specific disease mortality in hypertensives.
        Hypertension. 2013; 62: 485-491
        • Williams P.T.
        High-density lipoprotein cholesterol and other risk factors for coronary heart disease in female runners.
        N Engl J Med. 1996; 334: 1298-1303
        • Williams P.T.
        Relationship of distance run per week to coronary heart disease risk factors in 8283 male runners. The National Runners' Health Study.
        Arch Intern Med. 1997; 27;157: 191-198
        • Williams P.T.
        Reduced diabetic, hypertensive, and cholesterol medication use with walking.
        Med Sci Sports Exerc. 2008; 40: 433-443
        • Williams P.T.
        Distance walked and run as improved metrics over time-based energy estimation in epidemiological studies and prevention: evidence from medication use.
        PLoS One. 2012; 7: e41906
        • Williams P.T.
        Non-exchangeability of running vs. other exercise in their association with adiposity, and its implications for public health recommendations.
        PLoS One. 2012; 7: e36360
      1. National Center for Health Statistics. National Death Index user's guide. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/ndi/NDI_Users_Guide.pdf. Accessed May 10, 2013.

        • World Health Organization
        International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.
        World Health Organization, Geneva1992 (Centers for Disease Control and Prevention website) (Accessed October 5, 2012)
        • Ainsworth B.E.
        • Haskell W.L.
        • Whitt M.C.
        • et al.
        Compendium of physical activities: an update of activity codes and MET intensities.
        Med Sci Sports Exerc. 2000; 32: S498-S504
        • Williams P.T.
        Vigorous exercise, fitness and incident hypertension, high cholesterol, and diabetes.
        Med Sci Sports Exerc. 2008; 40: 998-1006
        • Chomistek A.K.
        • Cook N.R.
        • Flint A.J.
        • Rimm E.B.
        Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men.
        Med Sci Sports Exerc. 2012; 44: 1898-1905
        • Williams P.T.
        • Thompson P.D.
        Walking versus running for hypertension, cholesterol, and diabetes mellitus risk reduction.
        Arterioscler Thromb Vasc Biol. 2013; 33: 1085-1091
        • Kwong R.Y.
        • Chan A.K.
        • Brown K.A.
        • et al.
        Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease.
        Circulation. 2006; 113: 2733-2743
        • Williams P.T.
        • Franklin B.A.
        Reduced incidence of cardiac arrhythmias in walkers and runners.
        PLOS One. 2013; 8: e65302
        • Willich S.N.
        • Lewis M.
        • Löwel H.
        • Arntz H.R.
        • Schubert F.
        • Schroder R.
        Physical exertion as a trigger of acute myocardial infarction: Triggers and Mechanisms of Myocardial Infarction Study Group.
        N Engl J Med. 1993; 329: 1684-1690
        • Mittleman M.A.
        • Maclure M.
        • Tofler G.H.
        • Sherwood J.B.
        • Goldberg R.J.
        • Muller J.E.
        Triggering of acute myocardial infarction by heavy physical exertion: protection against triggering by regular exertion: determinants of Myocardial Infarction Onset Study Investigators.
        N Engl J Med. 1993; 329: 1677-1683
        • Mathews S.C.
        • Narotsky D.L.
        • Bernholt D.L.
        • et al.
        Mortality among marathon runners in the United States, 2000-2009.
        Am J Sports Med. 2012; 40: 1495-1500
        • Lavie C.J.
        • McAuley P.A.
        • Church T.S.
        • Milani R.V.
        • Blair S.N.
        Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox.
        J Am Coll Cardiol. 2014; 63: 1345-1354
        • Lavie C.J.
        • Milani R.V.
        • Ventura H.O.
        Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss.
        J Am Coll Cardiol. 2009; 53: 1925-1932
        • McAuley P.A.
        • Blair S.N.
        Obesity paradoxes.
        J Sports Sci. 2011; 29: 773-782
        • Lakkireddy D.R.
        • Gowda M.S.
        • Murray C.W.
        • Basarakodu K.R.
        • Vacek J.L.
        Death certificate completion: how well are physicians trained and are cardiovascular causes overstated?.
        Am J Med. 2004; 117: 492-498
        • Messite J.
        • Stellman S.D.
        Accuracy of death certificate completion: the need for formalized physician training.
        JAMA. 1996; 275: 794-796

      Linked Article

      • Cardiovascular Disease Mortality and Excessive Exercise in Heart Attack Survivors
        Mayo Clinic ProceedingsVol. 90Issue 1
        • Preview
          In an in-depth study of 2377 patients (mean age, 62.9 years; 32% women) published in the September 2014 issue of Mayo Clinic Proceedings, Thompson et al1 reported that higher levels of physical activity up to 7.2 metabolic equivalent of task-h/d were associated with survival benefits in heart attack survivors. Notably, physical activity beyond this level was found to be associated with poorer prognosis—a 2.6- and 3.2-fold increase in risk for all-cause and ischemic heart disease–related mortality, respectively.
        • Full-Text
        • PDF