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Exercise and fitness in the prevention of cardiovascular disease

Pamela S Douglas, MD
Section Editor
Christopher P Cannon, MD
Deputy Editors
Daniel J Sullivan, MD, MPH
Brian C Downey, MD, FACC


Inadequate physical activity has been recognized as an independent risk factor for premature development of coronary heart disease (CHD) [1]. It has been estimated that approximately 12 percent of all mortality in the United States is related to the lack of regular physical activity and that physical inactivity is associated with at least a twofold increase in the risk for coronary events [1].

The public has become well aware of this relationship and millions of Americans have embarked on voluntary exercise programs based upon the assumption that exercise will lead to effective prevention of CHD [2]. The medical profession supports the concept through recommendation of regular physical exercise both as a primary and as a secondary measure [3].

The role of both exercise and fitness in the primary and secondary prevention of cardiovascular disease (CVD) will be reviewed here. An overview of the benefits and risks associated with exercise is presented separately. (See "The benefits and risks of exercise".)

Evaluation of the evidence — Despite the enthusiasm, the evidence from clinical trials to establish the benefit of exercise is inadequate. There are several reasons for this limitation:

Successful, randomized clinical trials require good adherence in order to show a difference between the groups at the end of the study. In the case of exercise, it is not possible from an ethical or practical standpoint to prevent those assigned to the control group from engaging in exercise (drop-ins).

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Literature review current through: Oct 2017. | This topic last updated: Jan 27, 2016.
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  1. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health 1987; 8:253.
  2. Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation 1999; 99:963.
  3. LeFevre ML, U.S. Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2014; 161:587.
  4. Pahor M, Guralnik JM, Ambrosius WT, et al. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA 2014; 311:2387.
  5. Lemaitre RN, Siscovick DS, Raghunathan TE, et al. Leisure-time physical activity and the risk of primary cardiac arrest. Arch Intern Med 1999; 159:686.
  6. Shiroma EJ, Lee IM. Physical activity and cardiovascular health: lessons learned from epidemiological studies across age, gender, and race/ethnicity. Circulation 2010; 122:743.
  7. Reddigan JI, Ardern CI, Riddell MC, Kuk JL. Relation of physical activity to cardiovascular disease mortality and the influence of cardiometabolic risk factors. Am J Cardiol 2011; 108:1426.
  8. Eijsvogels TM, Molossi S, Lee DC, et al. Exercise at the Extremes: The Amount of Exercise to Reduce Cardiovascular Events. J Am Coll Cardiol 2016; 67:316.
  9. Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation 1996; 94:857.
  10. Fletcher GF, Balady G, Froelicher VF, et al. Exercise standards. A statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1995; 91:580.
  11. Smith JK, Dykes R, Douglas JE, et al. Long-term exercise and atherogenic activity of blood mononuclear cells in persons at risk of developing ischemic heart disease. JAMA 1999; 281:1722.
  12. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115:2358.
  13. Albert CM, Mittleman MA, Chae CU, et al. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 2000; 343:1355.
  14. Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, et al. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989; 262:2395.
  15. Blair SN, Kampert JB, Kohl HW 3rd, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205.
  16. Sandvik L, Erikssen J, Thaulow E, et al. Physical fitness as a predictor of mortality among healthy, middle-aged Norwegian men. N Engl J Med 1993; 328:533.
  17. Leon AS, Connett J, Jacobs DR Jr, Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial. JAMA 1987; 258:2388.
  18. Paffenbarger RS Jr, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993; 328:538.
  19. Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Circulation 2000; 102:975.
  20. Lee IM, Sesso HD, Paffenbarger RS Jr. Physical activity and coronary heart disease risk in men: does the duration of exercise episodes predict risk? Circulation 2000; 102:981.
  21. Lee IM, Sesso HD, Oguma Y, Paffenbarger RS Jr. Relative intensity of physical activity and risk of coronary heart disease. Circulation 2003; 107:1110.
  22. Ekelund LG, Haskell WL, Johnson JL, et al. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. The Lipid Research Clinics Mortality Follow-up Study. N Engl J Med 1988; 319:1379.
  23. Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. JAMA 1998; 279:440.
  24. Manson JE, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med 1999; 341:650.
  25. Manson JE, Greenland P, LaCroix AZ, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002; 347:716.
  26. Lee IM, Rexrode KM, Cook NR, et al. Physical activity and coronary heart disease in women: is "no pain, no gain" passé? JAMA 2001; 285:1447.
  27. Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003; 290:1600.
  28. Gulati M, Black HR, Shaw LJ, et al. The prognostic value of a nomogram for exercise capacity in women. N Engl J Med 2005; 353:468.
  29. Wagner A, Simon C, Evans A, et al. Physical activity and coronary event incidence in Northern Ireland and France: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). Circulation 2002; 105:2247.
  30. Tanasescu M, Leitzmann MF, Rimm EB, et al. Exercise type and intensity in relation to coronary heart disease in men. JAMA 2002; 288:1994.
  31. LaMonte MJ, Eisenman PA, Adams TD, et al. Cardiorespiratory fitness and coronary heart disease risk factors: the LDS Hospital Fitness Institute cohort. Circulation 2000; 102:1623.
  32. Laukkanen JA, Lakka TA, Rauramaa R, et al. Cardiovascular fitness as a predictor of mortality in men. Arch Intern Med 2001; 161:825.
  33. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002; 346:793.
  34. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:937.
  35. Blair SN, Kohl HW 3rd, Barlow CE, et al. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA 1995; 273:1093.
  36. Carnethon MR, Gidding SS, Nehgme R, et al. Cardiorespiratory fitness in young adulthood and the development of cardiovascular disease risk factors. JAMA 2003; 290:3092.
  37. Soares-Miranda L, Siscovick DS, Psaty BM, et al. Physical Activity and Risk of Coronary Heart Disease and Stroke in Older Adults: The Cardiovascular Health Study. Circulation 2016; 133:147.
  38. Noda H, Iso H, Toyoshima H, et al. Walking and sports participation and mortality from coronary heart disease and stroke. J Am Coll Cardiol 2005; 46:1761.
  39. Hakim AA, Petrovitch H, Burchfiel CM, et al. Effects of walking on mortality among nonsmoking retired men. N Engl J Med 1998; 338:94.
  40. Lee DC, Pate RR, Lavie CJ, et al. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014; 64:472.
  41. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097.
  42. Balady GJ, Larson MG, Vasan RS, et al. Usefulness of exercise testing in the prediction of coronary disease risk among asymptomatic persons as a function of the Framingham risk score. Circulation 2004; 110:1920.
  43. Mora S, Redberg RF, Sharrett AR, Blumenthal RS. Enhanced risk assessment in asymptomatic individuals with exercise testing and Framingham risk scores. Circulation 2005; 112:1566.
  44. Kokkinos P, Faselis C, Myers J, et al. Age-specific exercise capacity threshold for mortality risk assessment in male veterans. Circulation 2014; 130:653.
  45. Gulati M, Shaw LJ, Thisted RA, et al. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation 2010; 122:130.
  46. Newman AB, Simonsick EM, Naydeck BL, et al. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA 2006; 295:2018.
  47. LaMonte MJ, Barlow CE, Jurca R, et al. Cardiorespiratory fitness is inversely associated with the incidence of metabolic syndrome: a prospective study of men and women. Circulation 2005; 112:505.
  48. Yates T, Haffner SM, Schulte PJ, et al. Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance (NAVIGATOR trial): a cohort analysis. Lancet 2014; 383:1059.
  49. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:1883.
  50. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143:659.
  51. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116:682.
  52. Wannamethee SG, Shaper AG, Walker M. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation 2000; 102:1358.
  53. Steffen-Batey L, Nichaman MZ, Goff DC Jr, et al. Change in level of physical activity and risk of all-cause mortality or reinfarction: The Corpus Christi Heart Project. Circulation 2000; 102:2204.
  54. http://www.health.gov/paguidelines/pdf/paguide.pdf (Accessed on September 01, 2010).
  55. Hagberg JM, Montain SJ, Martin WH 3rd, Ehsani AA. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol 1989; 64:348.
  56. King AC, Haskell WL, Young DR, et al. Long-term effects of varying intensities and formats of physical activity on participation rates, fitness, and lipoproteins in men and women aged 50 to 65 years. Circulation 1995; 91:2596.
  57. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273:402.
  58. Williams PT. Relationship of distance run per week to coronary heart disease risk factors in 8283 male runners. The National Runners' Health Study. Arch Intern Med 1997; 157:191.
  59. Williams PT. High-density lipoprotein cholesterol and other risk factors for coronary heart disease in female runners. N Engl J Med 1996; 334:1298.
  60. Fletcher GF. How to implement physical activity in primary and secondary prevention. A statement for healthcare-professionals from the Task Force on Risk-reduction, American Heart Association. Circulation 1997; 96:355.
  61. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003; 107:3109.
  62. Forrester JS, Merz CN, Bush TL, et al. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 4. Efficacy of risk factor management. J Am Coll Cardiol 1996; 27:991.
  63. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694.