Association of All-Cause and Cardiovascular Mortality With High Levels of Physical Activity and Concurrent Coronary Artery Calcification

Abstract

IMPORTANCE Few data are available to guide clinical recommendations for individuals with high levels of physical activity in the presence of clinically significant coronary artery calcification (CAC). OBJECTIVE To assess the association among high levels of physical activity, prevalent CAC, and subsequent mortality risk. DESIGN, SETTING, AND PARTICIPANTS The Cooper Center Longitudinal Study is a prospective observational study of patients from the Cooper Clinic, a preventive medicine facility. The present study included participants seen from January 13, 1998, through December 30, 2013, with mortality follow-up through December 31, 2014. A total of 21 758 generally healthy men without prevalent cardiovascular disease (CVD) were included if they reported their physical activity level and underwent CAC scanning. Data were analyzed from September 26, 2017, through May 2, 2018. EXPOSURES Self-reported physical activity was categorized into at least 3000 (n = 1561), 1500 to 2999 (n = 3750), and less than 1500 (n = 16 447) metabolic equivalent of task (MET)-minutes/week (min/wk). The CAC scores were categorized into at least 100 (n = 5314) and less than 100 (n = 16 444) Agatston units (AU). MAIN OUTCOMES AND MEASURES All-cause and CVD mortality collected from the National Death Index Plus. RESULTS Among the 21 758 male participants, baseline mean (SD) age was 51.7 (8.4) years. Men with at least 3000 MET-min/wk were more likely to have prevalent CAC of at least 100 AU (relative risk, 1.11; 95% CI, 1.03-1.20) compared with those accumulating less physical activity. In the group with physical activity of at least 3000 MET-min/wk and CAC of at least 100 AU, mean (SD) CAC level was 807 (1120) AU. After a mean (SD) follow-up of 10.4 (4.3) years, 759 all-cause and 180 CVD deaths occurred, including 40 all-cause and 10 CVD deaths among those with physical activity of at least 3000 MET-min/wk. Men with CAC of less than 100 AU and physical activity of at least 3000 MET-min/wk were about half as likely to die compared with men with less than 1500 MET-min/wk (hazard ratio [HR], 0.52; 95% CI, 0.29-0.91). In the group with CAC of at least 100 AU, men with at least 3000 MET-min/wk did not have a significant increase in all-cause mortality (HR, 0.77; 95% CI, 0.52-1.15) when compared with men with physical activity of less than 1500 MET-min/wk. In the least active men, those with CAC of at least 100 AU were twice as likely to die of CVD compared with those with CAC of less than 100 AU (HR, 1.93; 95% CI, 1.34-2.78). CONCLUSIONS AND RELEVANCE This study suggests there is evidence that high levels of physical activity (Ն3000 MET-min/wk) are associated with prevalent CAC but are not associated with increased all-cause or CVD mortality after a decade of follow-up, even in the presence of clinically significant CAC levels.

Highly increased Troponin I levels following high-intensity endurance cycling may detect subclinical coronary artery disease in presumably healthy leisure sport cyclists: The North Sea Race Endurance Exercise Study (NEEDED) 2013

“…Exercise-induced hypertension, systemic inflammation with repeated bouts of exercise and exercise-induced parathyroid hormone increases may also be involved in development of calcified CAD (39). Importantly, even with higher coronary artery calcium levels in highly active subjects than in the more sedentary population, active subjects did not have increased all-cause or CVD mortality as compared to sedentary subjects in a large 10-year follow-up study (42).…”

“…Although moderate exercise reduces the risk of a cardiovascular event from coronary artery disease, recent cross-sectional studies have suggested a dose-dependent relation between life-long exposure to physical activity and the burden of myocardial fibrosis (39)(40)(41), coronary artery calcification (39,42,43) and atrial fibrillation in highly active subjects (44)(45)(46)(47). It is important to note that most of these studies are cross-sectional observational studies, and that a causal link between exercise and these pathophysiological processes has not been established.…”

Endurance exercise training volume is not associated with progression of coronary artery calcification

“…[3][4][5] These studies have suggested a dose-dependent relation between lifelong exposure to physical activity and calcified coronary artery disease (CAD). [3][4][5][6] This relationship, however, may seem contra intuitive, based upon the health and longevity of athletic subjects.…”

Coronary artery calcification: More than meets the eye

“…9 With such mounting evidence, not surprisingly, the American College of Cardiology has recently recommended that physicians use CAC to help reclassify patients with borderline to intermediate risk (10-year risk between 5% and 20%) to guide the initiation of have shown that some patients who are more physically fit, including marathon runners 11 and athletes 12,13 have higher levels of CAC than age-matched controls, but do not have increased cardiovascular morbidity and mortality. 14 This clinical paradox suggest that measuring plaque burden alone is not enough to risk stratify all patients.…”