Cardiorespiratory fitness and risk of heart failure with preserved ejection fraction

Peter Kokkinos; Charles Faselis; Andreas Pittaras; Immanuel Babu Henry Samuel; Carl J Lavie; Jose D Vargas; Michael Lamonte; Barry Franklin; Themistocles L Assimes; Rayelynn Murphy; Jiajia Zhang; Xuemei Sui; Jonathan Myers

doi:10.1002/ejhf.3117

Cardiorespiratory fitness and risk of heart failure with preserved ejection fraction

Eur J Heart Fail. 2023 Dec 28. doi: 10.1002/ejhf.3117. Online ahead of print.

Authors

Peter Kokkinos^{1

2

3}, Charles Faselis^{4

5}, Andreas Pittaras^{1

5}, Immanuel Babu Henry Samuel^{6

7}, Carl J Lavie⁸, Jose D Vargas¹, Michael Lamonte⁹, Barry Franklin¹⁰, Themistocles L Assimes¹¹, Rayelynn Murphy¹, Jiajia Zhang¹², Xuemei Sui¹³, Jonathan Myers^{14

15}

Affiliations

¹ Cardiology Division, DC Veterans Affairs Medical Center, Washington, DC, USA.
² Department of Kinesiology and Health, School of Arts and Sciences, Rutgers University, New Brunswick, NJ, USA.
³ Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
⁴ DC Veterans Affairs Medical Center, Washington, DC, USA.
⁵ Department of Medicine, George Washington University School of Medicine, and Health Sciences, Washington, DC, USA.
⁶ War Related Illness and Injury Study Center, DC Veterans Affairs Medical Center, Washington, DC, USA.
⁷ The Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
⁸ John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA.
⁹ Department of Social and Preventive Medicine, University of Buffalo, Buffalo, NY, USA.
¹⁰ Preventive Cardiology, William Beaumont Hospital, Royal Oak, MI, USA.
¹¹ Cardiology, Stanford University School of Medicine, Stanford, CA, USA.
¹² Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA.
¹³ Department of Exercise Science, University of South Carolina System, Columbia, SC, USA.
¹⁴ Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
¹⁵ Department of Cardiology, Stanford University, Stanford, CA, USA.

PMID: 38152843
DOI: 10.1002/ejhf.3117

Abstract

Aims: Preventive strategies for heart failure with preserved ejection fraction (HFpEF) include pharmacotherapies and lifestyle modifications. However, the association between cardiorespiratory fitness (CRF) assessed objectively by a standardized exercise treadmill test (ETT) and the risk of HFpEF has not been evaluated. Thus, we evaluated the association between CRF and HFpEF incidence.

Methods and results: We assessed CRF in US Veterans (624 551 men; mean age 61.2 ± 9.7 years and 43 179 women; mean age 55.0 ± 8.9 years) by a standardized ETT performed between 1999 and 2020 across US Veterans Affairs Medical Centers. All had no evidence of heart failure or myocardial infarction prior to completion of the ETT. We assigned participants to one of five age- and gender-specific CRF categories (quintiles) based on peak metabolic equivalents (METs) achieved during the ETT and four categories based on CRF changes in those with two ETT evaluations (n = 139 434) ≥1.0 year apart. During a median follow-up of 10.1 years (interquartile range 6.0-14.3 years), providing 6 879 229 person-years, there were 16 493 HFpEF events with an average annual rate of 2.4 events per 1000 person-years. The adjusted risk of HFpEF decreased across CRF categories as CRF increased, independent of comorbidities. For fit individuals (≥10.5 METs) the hazard ratio (HR) was 0.48 (95% confidence interval [CI] 0.46-0.51) compared with least fit (≤4.9 METs; referent). Being unfit carried the highest risk (HR 2.88, 95% CI 2.67-3.11) of any other comorbidity. The risk of unfit individuals who became fit was 37% lower (HR 0.63, 95% CI 0.57-0.71), compared to those who remained unfit.

Conclusions: Higher CRF levels are independently associated with lower HFpEF in a dose-response manner. Changes in CRF reflected proportional changes in HFpEF risk, suggesting that the HFpEF risk was modulated by CRF.

Keywords: Cardiorespiratory fitness; Heart failure with preserved ejection fraction incidence.