DOI: 10.1161/CIRCULATIONAHA.114.007641
Preventing Exercise-Related Cardiovascular Events:
Is a Medical Examination More Urgent for Physical Activity or Inactivity?
Running title: Franklin; Preventing Exercise-Related Cardiovascular Events
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Barry A. Franklin, PhD, FAHA
William Beaumont Hospital,
Hos
ospi
p tal, Royal Oak, MII
Ad
ddr
dres
ess for
for Correspondence:
C rr
Co
rres
esp
ponden
nd ncee:
Address
Barr
rryy A. Franklin,
Frankkli
l n,, PhD
PhD
h
Barry
Direect
c or
o , Pr
Prev
even
enti
tive
ti
ve C
ardi
ar
diol
ollog
ogyy an
andd Ca
Card
rdia
iacc Reha
R
eha
h bi
billita
litati
tion
ion
Director,
Preventive
Cardiology
Cardiac
Rehabilitation
William Beaumont Hospital
Beaumont Health Center
4949 Coolidge Hwy., Area C
Royal Oak, MI 48073
Tel: 248-655-5766
Fax: 248-655-5751
E-mail: [email protected]
Journal Subject Code: Diagnostic testing:[125] Exercise testing
Key words: Editorial, exercise, exercise testing
1
DOI: 10.1161/CIRCULATIONAHA.114.007641
Physical inactivity is a serious health problem worldwide, contributing to early development of
obesity, diabetes, hypertension, and cardiovascular diseases (CVD).1 In fact, our hypokinetic
lifestyle is now widely recognized among the most proximal risk factors for heart disease
(Figure 1), along with poor dietary habits and cigarette smoking.2-4 To address these concerns,
public health strategies commonly incorporate the goal of safely increasing physical levels in the
populations of industrialized societies. Accordingly, the number of health/fitness facilities and
members is expected to increase exponentially over the next decade. Current market research
indicates that the fastest growing user subsets are those aged 35 to 54 years and those •55 years
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
of age. These data, coupled with the recent finding that regular exercise prevents cellular
enescence, have led an increasing number of adults, many of whom have known
wnn oorr oc
ccult
cu
ult
senescence,
occult
chronic disease, to the conclusion that “more exercise is better.” Marathon running, for example,
example
ha
as in
incr
crea
cr
eaase
sedd in
n ppopularity
op
opularity
over the last 3 decade
des,
de
s w
ith participat
attio
i n in
inc
cr
creasing
from 25,000
has
increased
decades,
with
participation
increasing
unners
nn
n in 1976
19776 to
t approximately
app
pppro
oxi
xima
ima
mate
tely
te
ly 2 million
milllion in
in 2010.
20110.
10. Thus,
Thuus, we
we have
havve
ha
ve a population
popullat
atio
ionn paradox
para
pa
r do
ra
d x inn
runners
wh
hic
i h there
t er
th
eree is
is an
an expansion
expaanssio
expa
ion in
i the
the number
numb
nu
mber
mb
er of
of habitually
habbitu
ha
ual
ally
l sedentary
ly
sed
edent
ntar
nt
arry individuals
indi
in
diivi
vidu
d al
du
alss paralleling
para
pa
rall
ra
lleliing
ll
ing a
which
in
ncr
c ea
ease
s in
se
in those
th
hos
o e taking
taaki
king
ng
g part
par
artt in uunprecedented
npre
np
rece
re
cede
ce
d nt
de
nted
ed ho
hour
urss off vvigorous
ur
igor
ig
orou
or
ouss ex
ou
exer
erci
er
c se
ci
s .
concomitantt increase
hours
exercise.
Although numerous epidemiologic studies suggest that regular physical activity and/or
moderate-to-high levels of cardiorespiratory fitness, expressed as metabolic equivalents (METs;
1 MET = 3.5 mL O2/kg/min), may protect against the development of CVD, considerable
evidence now indicates that cardiovascular events, including acute myocardial infarction (AMI),
sudden cardiac death (SCD), stroke, and aortic dissection, can be triggered by vigorous physical
activity.5 To a large extent, the major cause of exertion-related cardiovascular events is the
combination of vigorous physical exertion and known or occult CVD, rather than the activity per
se. Thus, efforts to identify adults at increased risk generally focus on medical history, including
2
DOI: 10.1161/CIRCULATIONAHA.114.007641
symptomatology, cardiovascular risk factors and/or diagnostic testing to identify underlying
CVD.
Because “do no harm” remains a cardinal tenet of the Hippocratic Oath, professional
organizations have increasingly championed preparticipation self-screenings to identify ‘at risk’
individuals who should seek medical clearance, specially qualified supervisory staff/facilities, or
both, prior to embarking on an exercise program. The ingenious study by Whitfield et al,6
published in the current issue of Circulation, evaluated 2 commonly recommended selfscreening exercise preparticipation questionnaires, the American Heart Association
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
(AHA)/American College of Sports Medicine (ACSM) Preparticipation Questionnaire (AAPQ)
and the Physical Activity Readiness Questionnaire (PAR-Q), to clarify the utilit
ty off the
hese
he
see
utility
these
creening tools in a systematic manner.
screening
Usin
Us
ingg relevant
in
reele
levvant
va responses from the combined
comb
bin
inedd 2001-2004 National
Nat
a io
ona
nall Health and Nutrition
Using
E
xaamination
am
Surrvey
Su
ey (NHANES)
(NH
HAN
ANES
ES)) database,
data
da
tabbas
base, including
incclud
din
ng 6,
6,7
785 aadults
785
dul
ultts ((3,326
3 32
3,
3 6 me
menn an
andd 3,
33,459
4599 wo
45
wom
me
men)
Examination
Survey
6,785
women)
aged •
aged
4 years,
40
yea
ears
rs,, the
the investigators
in
nveest
stig
igaator
atorrs calculated
callcu
ca
lculat
ulat
ated
ed the
he gendergende
nder- and
and age-specific
ageag
e--sppec
ecif
ifficc proportions
pro
opo
port
rtio
io
ons ooff adul
aadult
dullt
•40
participants who
who would
wou
o ld
l receive
reccei
eive
v a rrecommendation
ve
ecom
ec
om
mme
mend
ndat
nd
atiion for
at
for
o physician
phy
hysi
sici
si
cian
ci
an consultation
con
onsu
sult
su
ltat
lt
atio
at
ionn be
io
befo
fore
fo
re sstarting
tarting an
before
exercise program based on AAPQ and PAR-Q referral criteria. Due to the depth and breadth of
topics covered by the AAPQ, as well as the number of “yes” responses required to flag a
respondent for referral to a physician, a relatively high rate of physician referral would have been
anticipated in this population. Nevertheless, the present findings were sobering, to say the least:
across all age groups •40 years, 95.5% (94.3–96.8%) of women and 93.5% (92.2–94.7%) of men
would be advised to consult a physician before exercise. For both genders, the proportion
referred increased with age and prescription medication use and decreased for those meeting
national physical activity guidelines; however, no age- or activity-group exhibited a referral
3
DOI: 10.1161/CIRCULATIONAHA.114.007641
proportion <75%. Compared with the results from the AAPQ, the PAR-Q, a previously
validated tool, yielded lower referral proportions for the sample as a whole, 68.4% versus 94.5%
for the AAPQ. The authors concluded that, in its present form, widespread use of the AAPQ
would result in excessive medical referrals, potentially placing an unnecessary burden on the
healthcare system, and present needless barriers to exercise adoption.6
Several study limitations were acknowledged by the investigators, including the fact that
5 items for the AAPQ did not have matching items in NHANES 2001-2004, and 3 notable
deviations were present in the matrix of PAR-Q items and their NHANES equivalents.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Nevertheless, these were appropriately accounted for in the data analyses. Additional limitations
ncluded insufficient information regarding how
w commonly the AAPQ is used (an
an
nd fo
foll
lllow
owed
ed),
ed
),
included
(and
followed),
eliability of the AAPQ using NHANES data, and whether respondents would answer AAPQ
reliability
tem
em
ms wi
with
th tthe
h sam
he
amee accuracy as their NHANES
am
S in
iinterviews.
terviews. Des
spi
p te th
hese
es limitations, the
items
same
Despite
these
au
uth
hor
o s focus was
waas too clarify,
claari
riffy,
fy, fo
forr th
he fi
ffirst
rstt tim
me,, thee uutility
tilit
itty off th
he A
he
APQ,
APQ,
Q a se
self
lf--scr
lf
-scree
eeni
ee
ning
ni
ngg ttool
ool th
ool
hat
authors
the
time,
the
AAPQ,
self-screening
that
end
ndor
o se
or
sedd by
b 2 professional
prrofe
rofeesssio
iona
nall organizations,
orrga
gani
niza
ni
zaation
ons,
on
s, the
thhe AH
AHA
A an
nd the
the ACSM,
ACSM
AC
SM,, relative
SM
rela
re
lati
tiive to
to the
the proportion
prop
pr
op
por
orttioon
iss endorsed
and
of adults •400 years
yea
e rs of
of age
ag
ge who
wh would
woul
wo
uldd be advised
ul
adv
dvis
ised
is
ed to
to consult
con
nsu
sult
lt a pphysician
hysiici
hy
c an before
bef
efor
o e starting
or
star
st
arti
ar
t ng
ti
n an
exercise program. It is in this clinical sphere where delineating the limitations of the current
self-screening tool, appears to be an important advance in our effort to more accurately identify
individuals at risk for exertion-related cardiovascular events.
The Risk-Protection Paradox of Exercise
The incidence of cardiovascular events during very light-to-moderate intensity activities is
extremely low and similar to that expected at rest. However, vigorous physical exertion,
especially when it is sudden, unaccustomed, or involving high levels of anaerobic metabolism,
appears to transiently increase the risk of AMI and SCD in susceptible individuals. Thompson et
4
DOI: 10.1161/CIRCULATIONAHA.114.007641
al,7 reported 1 jogging death per year for every 7,620 joggers in Rhode Island, or approximately
1 death per 396,000 hours of jogging. This rate was 7.6 times the hourly death rate during
sedentary activities. Vander et al,8 in a retrospective review of recreational physical activity,
documented 1 nonfatal event per 1,124,200 hours and 1 fatal event per 887,526 hours of
participation. Malinow et al,9 conducted a retrospective survey of the incidence of
cardiovascular events among participants at YMCA sports centers and found an even lower rate,
1 death per 2,897,057 person-hours. Collectively, these and other recent studies suggest that the
absolute risk of exercise-related SCD in the general population is very low, approximating
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1/565,000 person-hours.10
To clarify the risk of cardiac arrest and SCD associated with marathon an
and
nd ha
hhalflf-lf
marathons in the US from January 1, 2000 to May 31, 2010, investigators recently reported on
the
he in
inci
incidences
cide
ci
denc
de
ncees aand
nc
nd ooutcomes
utcomes of cardiovascularr eevents
v nts among 10.99 mil
ve
million
illi
lioon
li
on registered marathon
runners.
unners.
nn
n 11 Of th
the
he 59
59 cases
casees
es of
of cardiac
cardia
card
i c arrest
ia
arrest (mean
(mean
n ± SD
D age:
agee: 42±13
4 ±133 years;
42
yeaarss; 51
ye
51 men),
men)
me
n), 42 (71%)
n)
(71
71%
71
%)
were
we
ere
r ffatal.
a al
at
al.. T
The
he ooverall
veralll iincidence
vera
ncid
nc
den
e ce ooff ca
cardiac
ard
dia
iacc ar
arrest
rre
r st
st w
was
as 1 pper
er 1184,000
84
4,0
000 pparticipants,
arrti
tici
cipa
ci
pant
pa
nts,
s, aand
nd
d th
that
hat of
hat
of
SCD was 1 pe
perr 25
259,
259,000
9,00
9,
0000 pa
00
participants,
art
r ic
icip
pan
ants
tss, wh
whic
which
ichh tr
ic
translates
ran
ansl
s at
sl
a es
e too 0.
0.22 ca
cardiac
ard
rdia
iacc ar
arre
arrests
rest
re
stss an
st
and
nd 0.
0.14
14 S
SCDs
CDs per
100,000 estimated runner-hours. Sufficient information was available to suggest the cause of
cardiac arrest in only 31 of the 59 cases. The most frequent clinical and autopsy findings were
hypertrophic cardiomyopathy and atherosclerotic CVD, respectively.
To place the risks of exercise into perspective, it is important to consider that the absolute
risk associated with each bout of exercise is extremely low, the relative risk is inversely related
to the habitual level of activity, and the long-term cardioprotective effect of regular physical
activity is substantial. Using data from the Onset study,12 the risk of AMI associated with each
bout of physical activity is approximately doubled for an individual who engages in vigorous
5
DOI: 10.1161/CIRCULATIONAHA.114.007641
exercise •5 times per week for approximately 1 hour per session. However, during or soon after
an acute bout of vigorous exercise, the risk of AMI would be approximately 50 times higher for
the least active than for the most active cohort (Figure 2).13 Because regular exercise has been
reported to reduce the overall risk of CVD,14 during the remaining 23 hours of the day, the
habitually active individual’s risk would be up to 50% lower, highlighting the clear net benefit of
exercise.
Identifying the Individual at Risk: Limitations of Exercise Testing
Because of the vagaries of the atherosclerotic process, the accuracy of predicting who will
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experience an exercise-related cardiovascular event remains imperfect. Neither superior athletic
ability nor regular physical training, nor the absence of coronary risk factors, gua
uaara
rant
n eees
nt
guarantees
protection against an exercise death. One important clue, however, has emerged. Individuals
wh
o experience
expe
ex
peri
rien
ri
ence nnonfatal
en
on
onfatal
or fatal cardiovascular co
ccomplications
mplications du
uri
r ngg oorr ssoon
oon after exercise often
who
during
had prodromal
had
p odromaal symptoms
pr
syympto
mpto
oms
ms in
in the
the days
dayys
da
ys or
or weeks
weeeks
eks before
beefo
ore the
the
he event.
eveent
nt.5 Th
Thus
Thus,
uss, ph
phy
physicians
ysicia
ysi
icianns aand
nd aallied
llie
ll
ied
ed
health
heal
he
alth
al
th
h pprofessionals
rofe
ro
fesssio
fe
ssionnals
nals
l sshould
houldd pr
houl
prom
promote
om
mot
otee ed
education
duc
ucat
atiionn off eexertion-related
at
xerrtio
rtio
onn-re
rela
late
la
teed si
sign
signs/symptoms
gns//sy
gn
s mp
mpto
toms
to
ms iin
n the
the pa
pat
patients
tieents
they
hey counsel
counsel.
l.
There is controversy regarding the value and utility of medical screening procedures,
including peak or symptom-limited exercise testing, prior to initiating exercise programs. The
ACSM suggests that neither a medical examination nor exercise testing are needed in low risk
individuals (asymptomatic, <2 risk factors) embarking on a moderate intensity (40% - < 60%
VO2 reserve; 3 - <6 METs) or vigorous (•60% VO2 reserve; •6 METs) exercise program.15 On
the other hand, it recommends a medical examination in moderate risk individuals
(asymptomatic, •2 risk factors) before vigorous exercise as well as in high risk individuals
(symptomatic, or known cardiovascular, pulmonary, renal, or metabolic disease [ie, diabetes
6
DOI: 10.1161/CIRCULATIONAHA.114.007641
mellitus]) starting moderate or vigorous exercise regimens. Symptom-limited exercise testing is
also recommended in high risk individuals initiating either a moderate or vigorous exercise
program. Although the AHA/ACC have discouraged the use of exercise testing as a routine
screening procedure, their guidelines recommend exercise testing before vigorous exercise in
persons with known CVD.16 These guidelines further acknowledge the possible value of
exercise testing in persons with diabetes who are contemplating an exercise program and in men
>45 years and women >55 years who plan to start vigorous exercise programs.16 However, few
data are available to substantiate these screening recommendations or that physician consultation
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
improves exercise safety.6 The US Preventive Services Task Force found insufficient evidence
to
o support the use of exercise testing before exercise programs in low risk, asymptomatic
asym
mptom
omat
om
atic
at
ic
adults.17 Similarly, a systematic review of the evidence supporting the benefits and risks of
ph
hys
ysic
ical
ic
al aactivity
ctiv
ct
ivityy an
iv
andd structured exercise in olderr adults
ad
dults argued that
th
hat
a any
ny
y policy
pol
o icy (ie, the need for
physical
routine
outtin
i e exercise
exerciise testing)
testiing
ng)) that
that deters
dete
terrs
rs a large
lar
argge number
num
mbeer of
of people
peop
eople
pl fr
fro
from
om pparticipating
arti
ar
t cipaatin
ting
ng in
in an exercise
exeerc
rcis
isee
is
program
prog
pr
ogra
og
ram
ra
m ma
mayy ca
caus
cause
usee m
us
more
orre
re hharm
arrm th
than
an ggood.
oodd.
oo
d.188
Althou
ouugh eexercise
xerc
xe
rccis
i e te
test
stin
st
ng ma
mayy be
b hhelpful
e pf
el
pful
u iin
ul
n id
iidentifying
en
nti
t fy
fyin
ingg ex
in
eexertional
erti
er
tion
ti
onal
on
al aangina
n in
ng
inaa or tthreatening
h eatening
hr
Although
testing
ventricular arrhythmias, a truly “positive” exercise test requires the presence of a flow-limiting
coronary lesion, whereas most acute coronary events evolve from vulnerable plaque rupture at
mild-to-moderate stenoses.5 These findings, coupled with the extremely low incidence of
exercise-related cardiovascular complications in physically active asymptomatic persons, the
high rate of false-positive responses in some populations, the costs of routine exercise testing and
follow-up of abnormal results with expensive noninvasive/invasive studies, and the uncertainties
associated with abnormal exercise electrocardiographic (ECG) responses in persons with a low
7
DOI: 10.1161/CIRCULATIONAHA.114.007641
pre-test risk of coronary disease, suggest that it is impractical to use exercise testing to prevent
cardiovascular events in asymptomatic exercisers.9
Exercise: Who Benefits the Most?
The risk of coronary heart disease and CVD decrease linearly in association with increasing
levels of physical activity and aerobic capacity. However, there is a precipitous drop in risk
when comparing the lowest to the next lowest category for aerobic capacity (cardiorespiratory
fitness). Beyond this point, the reductions in risk parallel those observed with increasing
physical activity but are essentially twice as great for aerobic capacity.19
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Numerous epidemiologic studies have now shown that the risk for all-cause and
cardiovascular mortality is markedly increased in persons unable to achieve 5 METs
MET
ETss during
duri
du
ring
ri
ng peak
pea
e k
or symptom-limited exercise testing. Other reports suggest that this fitness demarcation also
renders
endderrs an
n iimportant
mpor
orrta
tant
n indicator of heightened shor
short-term
ortor
t-tterm perioperat
perioperative
ativee co
at
com
complications,
mplications, perhaps
providing
prov
viding an iindex
nddex
x ooff th
the
he pa
ppatient’s
ati
tieent
ti
ent’ss pphysiologic
hyysiologgic ca
capacity
apaacitty to ccope
ope w
with
ithh th
it
thee me
metabolic
etaabo
boli
lic de
li
dema
demands
mand
ma
ndss
nd
20
created
major
crrea
eate
teed by tthe
he ttrauma
raauma
uma off m
ajjor ssurgery.
urge
ur
gery
ry
y.20
cla
laari
r fy the
the
h question,
que
u sttio
ion,
n “Should
“Sh
S ou
Sh
o ld
d we
we be advising
adv
dvis
isin
is
i g our
in
our patients
pati
pa
tien
ti
e tss to
en
to walk
walk or
or run?,”
run
un?,
?,” researchers
?,
researcherrs
To clarify
used a meta-analysis to evaluate the effect of physical activity with different intensities on allcause mortality.21 The results showed a dose-response curve from sedentary subjects to those
with low-to-moderate exercise intensities, with only a minor additional mortality reduction with
vigorous physical activity. Collectively, these data suggest that habitually sedentary patients
should be regularly counseled to initiate and maintain a walking program, so as to move them
out of the least fit, least active, “high-risk” cohort (bottom 20%).22 Slow walking, even at 1 to 2
mph, approximates 2.0 to 2.5 METs and can constitute a sufficient training stimulus for this
patient subset. Avoidance of the lowest category of fitness/physical activity may be among the
8
DOI: 10.1161/CIRCULATIONAHA.114.007641
easiest interventions to introduce, and most likely to maintain, to favorably modify
cardiovascular and other related health outcomes. Thus, from a public health perspective, the
primary beneficiaries are those at the bottom of the fitness/activity continuum.
Although there appears to be an inverse relationship between peak METs and mortality,
Blair et al23 reported an “asymptote of gain” beyond which further improvements in
cardiorespiratory fitness conveyed no additional survival benefit. This asymptote was estimated
to be about 9 METs for women and 10 METs for men, approximate cut points that have been
substantiated by others.24 Blair et al23 concluded that the aerobic capacity values associated with
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the lowest death rates are attainable by most adults who engage regularly in moderate exercise
(eg,
eg, a brisk walk of 30 to 60 min each day). These data, and other recent reports,
reports
ts,, su
suggest
uggges
estt th
that
a
at
patients need not become endurance athletes or, for that matter, marathon runners, to achieve the
survival
urv
viv
ival
al bbenefits
enef
en
e itss of
of exercise.
C
lin
nic
i al Implications
Impli
lica
ca
atiion
ns
Clinical
Exercise
Ex
xer
e ci
cise
s may
se
may protect
pro
oteect against
aga
gain
inst
stt and
and provoke
provo
rovooke acute
acu
cute
te cardiac
carrdi
d ac events.
event
ventts.
s The
The risk
risk
sk ooff ca
ccardiovascular
r io
rd
ova
vasccular
ular
a
complications
complication
ns appears
appe
ap
pear
pe
a s to increase
ar
inc
n re
nc
r ase transiently
tra
ranssie
i nt
n ly during
dur
urin
ingg strenuous
in
s reenu
st
nuou
ouss physical
ou
phys
ph
yssic
ical
al eexertion
xerrti
xe
tion
on compared
com
ompa
p red with
the risk at other times. This seems to be particularly true among inactive persons with occult or
known CVD who engage in unaccustomed vigorous physical activity. However, the net effect of
regular physical activity is a lower overall risk of mortality from CVD.
Considering the cardiovascular benefits and risks of exercise, the former outweighs the
latter for the vast majority of adults, especially if one adopts a light-to-moderate exercise
intensity. Asymptomatic men and women who plan to be physically active at these levels do not
need to consult with a physician or health care provider unless they have specific medical
questions. Although exercise testing is recommended in coronary patients initiating either a
9
DOI: 10.1161/CIRCULATIONAHA.114.007641
moderate or vigorous exercise program,15,16 our empiric experience and previous studies have
demonstrated the safety and effectiveness of early outpatient medically supervised exercise
rehabilitation in selected cardiac patients, using adjunctive intensity modulators (eg, rating of
perceived and/or the patient’s resting heart rate plus 20-30 beats/min) and continuous ECG
monitoring, without a preliminary exercise test.25
In conclusion, numerous epidemiologic studies have shown that low-fit individuals are
approximately 2 to 5 times more likely to die during follow-up as compared with their more fit
counterparts, regardless of the presence or absence of coronary disease and/or associated risk
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factors (eg, overweight/obesity, diabetes).22 Perhaps Per-Olof Åstrand, MD, summed it up best
when he stated: “As a general rule, moderate activity is less harmful to health than
th
han inactivity.
ina
nact
ctiv
ct
ivit
iv
ity.
it
y
y.
You could also put it this way: a medical evaluation is more urgent for those who plan to remain
inactive
naccti
tive
ve than
tha
hann forr those
thos
th
o e who intend to get into good
goood
od physical
physical shape.”
shape.
e”
e.
Conflict
None.
Co
onf
nfli
l ct
c of Interest
Inteere
In
restt Disclosures:
Dissclossurres
es: N
onne.
References:
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Figure Legends:
Figure 1. The evolutionary CVD pyramid. Unhealthy lifestyle practices lead to risk factors, the
progression of CVD, and, ultimately, adverse outcomes or clinical endpoints. The first-line
strategy to prevent initial or recurrent cardiac events is to favorably modify unhealthy lifestyle
habits, including cigarette smoking and poor dietary habits and physical inactivity. In 2000,
12
DOI: 10.1161/CIRCULATIONAHA.114.007641
these habits were responsible for an estimated 435,000 and 365,000 deaths, respectively.4 CVD
signifies cardiovascular disease; MI indicates myocardial infarction; CHF, congestive heart
failure; and PAD, peripheral arterial disease. Adapted for Mozaffarian D, et al2 and Franklin BA
and Cushman M.3
Figure 2. Relative risk of acute myocardial infarction at rest and during vigorous physical
exertion (•6 METs) in sedentary and physically active individuals, with specific reference to the
habitual frequency of vigorous exertion (days/week). Adapted from Mittleman MA, et al.12,13
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
13
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Figure 1
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Figure 2
Preventing Exercise-Related Cardiovascular Events: Is a Medical Examination More Urgent
for Physical Activity or Inactivity?
Barry A. Franklin
Circulation. published online January 13, 2014;
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
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