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Exercise and coronary heart disease secondary prevention: is more better?

by Luis Serratosa - EAPC Sports Cardiology Section



Current guidelines on secondary prevention of stable coronary heart disease (CHD) recommend similar levels of regular moderate (150 min/week) or vigorous (60-75 min/week) exercise to those recommended for primary prevention of cardiovascular (CV) disease. However, these recommendations are based on limited evidence and very high intensity and duration of exercise may increase the CV risk. 

The present observational study analyzed the relationships between the amount (hours/week) of mild (< 3 METS), moderate (3-6 METS), and vigorous (>6 METS) physical activity assessed by self-reported questionnaire and subsequent all-cause mortality, CV mortality, non-CV mortality, MI, and stroke in a large cohort of 15,486 patients from 39 countries with stable CHD who participated in the global STABILITY (Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy) trial, during a median follow-up of 3.7 years.

Results showed that there was a gradually lower all-cause, CV, and non-CV mortality at gradually higher habitual exercise and the difference was greater at lower levels exercise, and less pronounced at higher levels of exercise. Myocardial infarction and stroke were not associated with exercise volume after adjusting for covariates. The findings suggest important potential benefits of increasing habitual exercise in persons with stable CHD who are sedentary.

The minimal effective dose of physical activity (PA) to reduce the mortality risk may actually be lower than current recommendations and this should stimulate patients to incorporate feasible goals in their daily lives.

The association between decrease in mortality and greater physical activity was also stronger in the subgroup of patients at higher risk estimated by the ABC-CHD (Age, Biomarkers, Clinical–Coronary Heart Disease) risk score. These observations suggest that persons with more advanced disease and/or limiting symptoms, who are often also more sedentary, could have the most to benefit from increasing habitual exercise.

As recognized by the authors, an important limitation of the study is that self-reported questionnaires are subjective and may overestimate PA volumes. Nevertheless, it could be assumed that PA health related benefits would start at even lower PA volumes than those estimated in the present study. In summary, even if it is true that vigorous intensity PA was associated with the lowest mortality risk, from my point of view, the main findings of this interesting study are that among CHD patients, low volumes of PA (as little as 10 min/day of brisk walking (5.5 km/h) or 15 to 20 min/day at a slower pace (3.2 to 4 km/h) are associated with large risk reductions for all-cause and cardiovascular mortality.

So as concluded by the authors, the greatest benefits to health are likely to be achieved by modest increases in exercise in sedentary persons, especially in persons who have a higher risk of adverse events, and those with exertional angina and dyspnea. 

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology

References

Luis Serratosa commented on this article:

Physical activity and mortality in patients with stable coronary heart disease

Stewart RAH, Held C, Hadziosmanovic N, et al.

J Am Coll Cardiol 2017;70:1689–700.

Additional references:

1. Eijsvogels TMH, Maessen MFH. Exercise for coronary heart disease patients. Little is good, more is better, vigorous is best. Editorial comment. J Am Coll Cardiol 2017;70:1701-3.