Attention to patients’ physical activity trajectories should become routine in coronary heart disease (CHD) clinical practice, said the researchers of a new longitudinal study that highlights the potential benefit of preserved or increased activity.
The study also found that the benefits of past activity can be “weakened or lost” if physical activity is not maintained – a fact that may be confounded by disease progression.
The study was published Monday online ahead of the May 3 issue of the Journal of the American College of Cardiology, with authors led by the University of Bern’s Nathalia Gonzalez-Jaramillo, MD, MSc.
CHD carries increased risks of all-cause and cardiovascular disease mortality, threats that are known to be reduced with American and European-recommended regular physical activity, according to patient ability, said the researchers.
Mechanisms behind the protective nature of physical activity in CHD could include endothelial function improvement, anti-atherosclerotic and anti-inflammatory effects, they said.
However, evidence of the effect of changing physical activity patterns over time remains inconclusive, the researchers said. Some studies report no impact from physical activity trajectories – whether keeping active over time or increasing/decreasing activity – while others have reported higher or lower mortality risk in CHD patients who change their activity levels.
“To date there has been no synthesis of literature on the impact that lifestyle [physical activity] trajectories have on CHD patients,” said the researchers. “A thorough evaluation of the current evidence could be crucial to eventually informing prevention guidelines for patients with CHD.”
The systematic review and meta-analysis of 33,576 CHD patients pooled from five databases was, therefore, conducted to determine the association of longitudinal physical activity trajectories with both all-cause and cardiovascular disease (CVD) mortality.
More than 12,000 published papers were screened, identifying 42 cohort studies that assessed physical activity and mortality over time, of which nine studies with multiple measures for physical activity and all-cause mortality were ultimately included in the meta-analysis.
Of the nine studies, six included cardiovascular-specific mortality, four were in patients who had acute CHD, and five were in cohorts with chronic CHD.
All studies assessed physical activity through validated questionnaires, and mortality was “well documented,” the researchers noted.
The mean age among the full cohort was 62.5 years, and the maximum follow-up was 15.7 years. Four physical activity trajectories were defined: inactive over time, active over time, increased activity over time and decreased activity over time.
Compared with patients who were always inactive over time, the risk of all-cause mortality was 50% lower in those who remained active (hazard ratio [HR]: 0.50; 95% confidence interval [CI]: 0.39-0.63).
Again compared to always-inactive patients, all-cause mortality risk was 45% lower in those who were once inactive but who became active (HR: 0.55; 95% CI: 0.44-0.7) and was 20% lower in those who had been active but become inactive (HR: 0.80; 95% CI: 0.64-0.99).
Similar results were observed for CVD mortality (always active HR: 0.49; 95% CI: 0.39-0.62 and increased activity HR: 0.63; 95% CI: 0.51-0.78) except for in the category of decreased activity, where CVD mortality was “not statistically different” compared with those who remained inactive (HR: 0.91; 95% CI: 0.67-1.24).
“This may indicate that active patients should be encouraged to preserve active lifestyles after CHD,” said the researchers.
“These results also imply that irrespective of previous [physical activity] levels, it is particularly important how patients change their [physical activity] over time following a diagnosis of CHD.
“Patients with established CHD can overcome prior years of inactivity and obtain survival benefits similar to those who remained active. However, the benefits of [physical activity] can be attenuated or even lost if the activity is not maintained.”
The results are applicable for patients in both the acute and chronic CHD settings, the researchers added, as well as for patients who change their activity patterns before and after CHD onset.
The findings show the potential benefit of adopting or preserving an active lifestyle for CHD patients, the researchers concluded, and that said benefits can dwindle or disappear if physical activity is not maintained.
Routine practice changes
“Based on a broad base of evidence from different countries, this meta-analysis provides new insights on [physical activity] trajectories that imply benefits from adopting a more active lifestyle and the possible harms of adopting a less active lifestyle among CHD patients,” the researchers said.
“Beyond the results from clinical trials performed in cardiac rehabilitation settings, we provided long-term real-world evidence showing that the survival benefits of lifestyle [physical activity] for CHD patients are likely not solely dependent on past levels of activity, but are combined with present levels of [physical activity] as well.
“Our results have important implications for clinical practice. The evaluation of habitual [physical activity] and the analysis of individual trajectories should become part of the routine work-up of CHD patients.”
‘Use it or lose it’
There will be no long-term randomized trials that have groups assigned to maintaining, increasing, reducing or stopping physical activity, Baylor College of Medicine’s Christie M. Ballantyne, MD, and University of Texas Medical Branch at Galveston’s John W. Davis, BA, stressed in an accompanying editorial.
“Thus, this meta-analysis provides the highest level of evidence generated on the long-term benefits of physical activity and survival in CHD patients.”
Although the authors’ allowance of both retrospective and prospective study designed in the study’s database search was “potentially dangerous, as this is only reliable when there is strong certainty that the measured exposures are not different across study designs,” the editorialists commended the work and the researchers’ “appropriate” use of random-effects weighting.
The study’s message is, in any case, “clear and straightforward,” they added: “Physical activity is extremely important for long-term outcomes in the patient with CHD! Increasing physical activity after an event is highly beneficial, and conversely, if an individual becomes inactive, much of the benefit is lost, which is supportive of the phrase ‘use it or lose it’.”
Gonzalez-Jaramillo N, Wilhelm M, Arango-Rivas AM, et al. Systematic Review of Physical Activity Trajectories and Mortality in Patients With Coronary Artery Disease. J Am Coll Cardiol 2022;79:1690-1700.
Ballantyne CM, Davis JW. Exercise and Mortality in Heart Disease Cohorts: Meta-Analysis to Augment Available Evidence. J Am Coll Cardiol 2022;79:1701-1703.
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