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Saturday, January 14, 2017

The minimum exercise levels of the 2008 guidelines won't prevent heart failure.

IMPORTANT CORRECTION:Since this commentary was posted I  realized I misinterpreted the two articles I quoted leading to the title conclusion which is incorrect.That has been corrected on 9/6/18 by the posting entitled " Is the minimal level of recommended exercise sufficient to decrease the risk of heart failure?"

The 2008 U.S. and WHO  exercise guidelines recommend a minimum of 2.5 hours of moderate intensity exercise per week or 1.25 hours of vigorous exercise per  week. This can be expressed as 500 METS Min per week or 8.3 MET hours per week.

This minimum value is widely quoted but often unnoticed is that  the panel also suggested that further gains could be made by increasing those exercise levels to twice those values, i.e 5 hours of moderate or 2.5 hours of vigorous exercise.

 Moderate intensity was defined as between 3 and 5.9 METS and vigorous as over 6 METS.For example running at a 15 min per mile pace is about 7 METS which would be the lower end of what the panel meant by vigorous.(This does not address the problem of relating exercise levels to a person's exercise capacity. For example, to  a person with a 02 max of 60 a fifteen minute mile is  mild exercise while the same pace for someone with a 02 max of  25 the term vigorous is  appropriate. Since age strongly correlates with 02 max should  the guidelines somehow take age into consideration in the recommendations.How to do that is not clear.

Cardiovascular disease (CVD) risk reduction has been shown in a number of epidemiological studies for people exercising at those  minimum levels and arguably at even lower level. Lee et al (1) showed that running at little as 5 to 10 minutes per day would significantly  reduce CVD mortality.This would make a little running seem very effective  while others (Pandy et al see below) did not show that degree of risk reduction with that low  level of exercise but the minimal recommended  level will likely reduce CVD risk according to several epidemiologic studies.

Eijsvogels (2) reported that the maximal risk reduction was found at a volume of 41 MET-hrs/week, which is 3-4 times the minimal recommended level.However, only 3.5% of the subjects exercised at that level or above and therefor the confidence interval for  hazard ratio (HR) estimation was wide and not statistically significant. The authors emphasized that they found no evidence of harm or adverse cardiovascular outcomes at this level but the relatively small number  of people in that category raises the possibility of a type11 error.

While rather low levels of exercise seem to decease CVD risk, heart failure  risk  reduction may require higher levels of exercise. Pandy et al (3) and coworkers from Southwestern Medical School reported that heart failure (HF) risk reduction occurred only at levels  significantly higher than the minimum guideline recommended values. "We observed a linear dose response for HF risk with a marked reduction in risk at very high doses of PA (physical activity  ) ( 35% risk reduction in HF risk at 2000 MET-min per week)".. This would be 4 times the minimal recommended value or 10 hours of moderate or 5 hours of vigorous exercise per week.

Schnohr et al (4) reported that their analysis of a data set from the Copenhagen City Heart Study demonstrated a U shaped association between all cause mortality and dose of jogging. A number of other articles cited by Schnohr  in that publication actually report a inverse relationship  showing no U or J shape. Accepting the thesis of  the existence of a U shape curve, he goes to comment on results from several large studies and speculates where the curve might ascend.The studies found that running  about 35 miles per week was the upper limit of incremental health benefits and "these studies found that a weekly cumulative dose of approximately 30 miles of running per week or 46 miles of walking is approximately the "safe" ( my quotes) upper limit for optimizing long term CV health and life expectancy", So if the curve turns upward  it does not seem to do so at running volumes in the 30 miles per week range. This volume of running would seem  satisfy the running volume "requirement" sufficient to decrease HF risk. suggested by Pandy's work..

So the epidemiological data would tend to confirm that the 2008 minimum guidelines would decrease CVD and all cause mortality but not the risk of heart failure which seems to  require at least twice that level of exercise.

Several publications from a group in Dallas (5) provide useful insights regarding the mechanism by which a higher level of exercise might  lessen heart failure risk, that is diastolic heart failure ( i.e  heart failure with preserved resting ejection fraction frequently abbreviated as HFpEF).

 Dr Paul Bhella and his  associates  did extensive physiological studies on four groups of healthy volunteers over the age of 64. Four groups were designated   on the basis of their exercise history for the preceding 25 years. (not a typo) 1) sedentary-no more than one exercise session per week  2) casual exerciser-2-3 session per week 3) "committed" exercisers-4-5 session per week and 4)competitive master level athletes -6-7 session per week and competed regularly.  All had normal systolic function ( as defined by a normal resting ejection fraction) but groups one and two has decreased left ventricular compliance while the committed and competitive groups had left ventricular pressure volume curves and left ventricular masses similar to young healthy controls. ( see here for my  further comments and a few caveats regarding this paper including reference to Tanaka's work that challenges the notion that long term endurance exercise  does in fact preserve  ventricular compliance)

Quoting Bhella ". . at least 30 minutes of dynamic exercise per session for 4-5 days per week over a lifetime can  sufficiently prevent most of the decreases in LV compliance and distensibility observed with sedentary aging" So the idea is that sedentary aging leads to stiff left ventricle and life long running may mitigate that process.

 In other words 2.5 hours of vigorous exercise per week which was the higher level of exercise ( i.e. twice the minimum  recommenced by the 2008 panel) might beneficially reduce the age related increase in ventricular stiffness. It does not take that much exercise per week but you have to put in a lot of weeks- and it was vigorous. Remember  Bhella's groups activity levels were for the 25 years before the testing. The authors speak of Lifelong exercise. 

 This exercise level is far below the typical exercise histories that one typically  finds in the cases of athletes with atrial fibrillation or the athletes in whom an abnormal gadolinium uptake was reported and whose cases are  sometimes emphasized by various writers warning the public about the dangers of "excessive exercise". I suggest that  2 to 3 times the  2008 Panel's minimal recommendation should not be considered excessive.

1)Lee, D  Leisure-time Running Reduces All-cause and cardiovascular mortality risk. JACC 64. 472-481.2014

2) Eijsvogels, T, Exercise at the extremes-The amount of exercise to reduce cardiovascular event
JACC, 67, 316-329, 2016

3)Pandey,A Dose-Response Relationship between Physical Activit and Risk of Heart Failure.A meta-Analysis, Circulation 2015, 132 1786-1794

 4) Schnohr,P Dose of Jogging and Long term Mortality. JACC, 65, 311-410,2015

 5)Bhella, P Impact of Lifelong Exercise "dose" on left ventricular compliance and Distensibility.
JACC 64, 1257-1267 2014

John VonNeumann " There's no sense in being precise when you don't even know what your're talking about"

addendum: 5/22/17 Several editorial flourishes made  and spelling errors corrected and more were made on 9/3/18. 9/6/18 Notification posted on this commentary referencing the correction made on 9/6/18.

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