HEARTBEATA Publication of South Jersey Heart Group

May 2019

Good News In a study of nearly 150,000 adults, the higher heart

disease risk and shorter lifespan associated with sitting

can be reversed in many people with moderate exercise—

at least 30 minutes a day on most days of the week2

(as recommended in the guidelines). The exception

was people who sat for more than eight hours a day.

Moderate amounts of exercise lowered, but didn't erase,

their higher risk of death. They need heavier amounts

of exercise for that. This is especially important in light

of new data that adolescents and adults are sitting about

an hour more a day now than about 10 years ago. This

appears to be driven largely by our increase in leisure-

time computer use.3 The authors caution, “Going from

zero minutes to 60 minutes of exercise every day is

tough. So just try adding a little bit of activity each day.”

Take Home: The findings from these two studies

underscore an important public health message that

physical activity of any intensity provides health benefits.

Move more, sit less! What we do when we’re not sitting matters.

Even Just a Little We’re assuming the title of this Heartbeatwill get a fewmore clicks than usual (online viewers), and we urgeyou since you came this far to read on. Even just a littleis good—and a lot is even better.

Is Sedentary Activity Dangerous?

The answer is yes! Inactivity causes 10 percent of premature mortalities in the U.S. About one in fouradults spends more than eight hours a day sitting, according to a recent study. Adults who sat for longstretches at a time—an hour or more without interruption—have a greater risk of early death thanthose who were sedentary for the same total amountof time but got up and moved around more often.“This is us”—not the TV show.

A new study of around 8,000 middle-aged and olderadults found that swapping a half-hour of sittingaround with physical activity of any intensity or duration cut the risk of early death by as much as 35percent with moderate-to-vigorous activity (Table 1)and 17 percent with low-intensity activity (any movement).1 The findings highlight the importance of movement—regardless of its intensity or amount of time spent moving—for better health.

Brisk Walking (>3 miles/h) Uphill walking or race walking

Bicycling (<10 miles/h) Bicycling (>10 miles/h)

Water aerobics Running or jogging

Tennis (doubles) Tennis (singles)

Ballroom dancing Aerobic dancing

General gardening Heavy gardening (digging/hoeing)

Moderate-IntensityAerobic Activities>150 min/week

Vigorous-IntensityAerobic Activities>75 min/week

TABLE 1Examples of Moderate-and Vigorous-Intensity Activities to Achieve 2008 Exercise Guideline Recommendations

New Physical Activity Guidelines for AmericansNew guidelines were presented at the American HeartAssociation meeting in November 2018. Adults shoulddo at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes aweek of vigorous-intensity aerobic physical activity, oran equivalent combination of moderate- and vigorous-intensity aerobic activity.4 A new addition to theseguidelines is adults should also do muscle-strengtheningactivities on two or more days a week. Older adultsshould do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Adults with chronic conditionsor disabilities, who are able, should follow the keyguidelines for adults and do both aerobic and muscle-strengthening activities. Recommendations emphasizethat moving more and sitting less will benefit nearlyeveryone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic cardio and muscle-strengthening physical activity are beneficial.

Writing ”move more, sit less” on a piece of paper doesn’tmean that we created an infrastructure incentive to doit. The idea is that everything no matter how minimal isa good thing. The idea is to have one start off small. Forexample, we recommend walking. which is the easiestexercise for most individuals, and then people can buildon that—in particular movement that gets people out of breath, such as fast walking, stair climbing, walkinguphill or carrying groceries. Mini wins of activity add up to maxi wins down the line.

Physician Incentive We can’t emphasize enough how important it is for usto share this information with our patients. The benefitsare unending. If exercise came in pill form, every doctorwould prescribe it for every condition. We’re all busyand everything takes time. The next step is to ensurethat practices are reimbursed for spending time with patients providing advice about how to increase physical

activity. Last fall, a new ICD-10 code (Z71.82) was released for exercise counseling, and we’d like to promotethis as part of the effort to advance the guidelines. Itwould also be great to see exercise professionals be compensated like physical therapists for working with patients to improve their fitness, not just in cardiac rehab or after injury or surgery, but for overall health promotion. We would advise and then write the script.

Can We Overdose? The answer is an absolute NO! Is there an upper levelof benefit? Again, the answer is no.

Exercise treadmill testing (ETT)—Bruce Protocol (Figure 1)—is the most widely used method to measure cardiorespiratory fitness (CRF) and serves as an objectivemeasure of aerobic fitness and moderate-vigorous physical data. Previous studies5, 6 of CRF and mortalityhave not specifically identified or analyzed patients withextremely high CRF, and it remains unclear whether there is an upper limit of CRF above which no furtherbenefit or even harm is seen.

We know that CRF based on achievement of 10 metabolicequivalents (METs) during ETT have less chance of death from any cause.7 The following study assesses the association between aerobic fitness and all-cause mortality among the largest reported cohort, of adult patients undergoing ETT at a tertiary care center.8

Patients with extremely high CRF (elite performers; CRF ≥2 standard deviations [SDs] above the mean for age and sex) were identified to evaluate the relative benefit or harm of extreme CRF compared with moremodest levels of aerobic fitness.

In this cohort study of 122,007 consecutive patients undergoing ETT, CRF was inversely associated with all-cause mortality without an observed upper limit of

Stage Minutes % grade MPH METS

1 3 10 1.7 3-5

2 3 12 2.5 6-7

3 3 14 3.4 7-10

4 3 16 4.2 10-12

5 3 18 5.0 14

6 3 20 5.5 17

7 3 22 6.0 21

Figure 1ETT Bruce Protocol

benefit. Elite CRF (≥2 SDs above the mean for age and sex) was associated with the lowest risk-adjustedall-cause mortality compared with all other performancegroups (Table 2).

Comment: Potentially adverse cardiovascular (CV) findings in highly active people, including an increasedincidence of atrial fibrillation, coronary artery calcification, myocardial fibrosis and aortic dilation, areprobably just benign features of CV adaptation based on this study. Elite performers undergoing ETT had a significant association with reduction in all-cause mortality (CV, stroke and cancer)—and live longer whencompared with any other performance group. Overall,increases in CRF were associated with a reduction in all-cause mortality at any level. There does not appear to be an upper limit of aerobic fitness above which a survival benefit is no longer observed.

A cheaper method (without ETT) to determine goodfunctional capacity (>10 METs) would be walking upthree floors of stairs very fast without stopping, or fast

up four floors. Another would be being able to perform11 or more push-ups at baseline—associated with significantly reduced risk of subsequent CVD events.9

Reduced CRF was greater than or equal to traditionalclinical risk factors, such as CVD, diabetes and smoking.Extreme aerobic fitness (CRF ≥2 SDs above the mean for age and sex) was associated with the greatest survival in older patients and those with hypertension.This study reinforces the clinical utility of using ETT todetermine patient prognosis.

Take Home: Sedentary activity is unhealthy and associatedwith increased CV risk. This risk can be eased with moderate exercise. All activity is good and decreases CVrisk. More is better without any observable upper limit of benefit. We have to share the exercise guidelines andbenefits to encourage our patients to exercise more (asmuch as possible) to achieve higher levels of fitness.

Special Guest Editor: Andrew Mehalick, DO, Cardiology Fellow, PGY VI

Mario L. Maiese, DO, FACC, FACOI Clinical Associate Professor of Medicine, Rowan SOM

Email: maiese1@comcast.net

Sign-up to receive Heartbeat online: www.sjhg.org. Heartbeat is a South Jersey Heart Group publication.

“Yeah, but for a fat guy who doesn’t exercise I’m in pretty good shape. ”

PERFORMANCE GROUP

Age Low Below Average Above Average High Elite

WOMEN

18-19 <10 10-11 11.1-12.9 13-14.9 ≥15

20-29 <8 8-9.9 10-11.4 11.5-14.2 ≥14.3

30-39 <7.7 7.7-9.3 9.4-10.8 10.9-13.6 ≥13.7

40-49 <7.4 7.4-8.9 9.0-10.3 10.4-13.2 ≥13.3

50-59 <7 7-8 8.1-9.9 10-12.9 ≥13

60-69 <6 6-6.9 7-8.4 8.5-11 ≥11.1

70-79 <5 5-5.9 6-6.9 7-9.9 ≥10

≥80 <4.4 4.4-5.4 5.5-6.2 6.3-8.3 ≥8.4

TABLE 2Classification of Cardiorespiratory Fitness by Age and Sex

MEN

18-19 <10.8 10.8-12.9 13-13.9 14-16.2 ≥16.3

20-29 <10.3 10.3-11.9 12-13.6 13.7-15.6 ≥15.7

30-39 <10 10-11.1 11.2-12.9 13-14.9 ≥15

40-49 <9.8 9.8-10.9 11-12.4 12.5-14.6 ≥14.7

50-59 <8.2 8.2-9.9 10-11.3 11.4-13.9 ≥14

60-69 <7 7-8.4 8.5-9.9 10-12.9 ≥13

70-79 <6 6-6.9 7-8.4 8.5-11.4 ≥11.5

≥80 <5.1 5.1-6.2 6.3-7.2 7.3-9.9 ≥10

Ranges are given in metabolic equivalents (METs), withone MET equaling 3.5mg/Kg per minute of oxygen consumption. Classification (percentile range) is as follows: low (<25th percentile), below average (25th-49thpercentile), above average (50th-74th percentile), high(75th-97.6th percentile), and elite (>97.7th percentile).

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Our Lady of LourdesMedical Center

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References

1 Diaz KM, Duran AT, et al. Potential Effects on Mortality of Replacing Sedentary Time With Short Sedentary Bouts or Physical Activity: A National Cohort Study. American Journal of Epidemiology March 2019; 188: 537-544.

2 Stamatakis E, Gale J, Bauman A, Ekelund U, Hamer M, ding D. Sitting time, physical activity, and Risk of Mortality in Adults. J Am Coll Cardiol April 2019; 73: 2062–2072.

3 Yang L, Cao C, Kantor ED, et al. Trends in Sedentary Behavior Among the US Population, 2001-2016. JAMA April 23/30 2019; 321: 1587-1597.

4 Piercy KPL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA November 20 2018; 320: 2020-2028.

5 Blair SN, Kohl HW III, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA 1989; 262: 2395-2401.

6 Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the risk of death in women: the St James Women Take Heart Project. Circulation. 2003;108 :1554-1559.

7 Peteiro J, et al. Abstract P927. Presented at: EuroEcho-Imaging; December 5-8 2018 Molan.

8 Mandsager K, Harb S, Cremer P, Nissan SE et al. Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults Undergoing Exercise Treadmill Testing. JAMA Netw Open. October 2018; 1: e183605. doi:10.1001/jamanetworkopen.2018.3605.

9 Yang J, Christophi CA, Farioli A, et al. Association Between Push-up Exercise Capacity and Future Cardiovascular Events Among Active Adult Men. JAMA Netw Open. 2019; 2(2): e188341. doi:10.1001/jamanetworkopen.2018.8341.